Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? Show
Pregnancy induced hypertension. Rationale: A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide? The fetus in utero is capable of hearing and does respond to the mother's voice. Rationale: A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide? The pregnancy should progress normally and be considered low risk. Rationale: What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal ? Swaddle the infant snugly and hold tightly. Rationale: The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? Avoid alcohol because it is excreted in breast milk. Rationale: A primigravida at 12-weeks gestation who just moved to the United States indicates she has not received any immunizations. Which immunization(s) should the nurse administer at this time? (Select all that apply.) Tetanus. Correct selections are (A, C, and E). Rationale: A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide? The fetus can respond to sound by 24-weeks gestation. Rationale: A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? Changes in fetal heart rate patterns. Rationale: The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address that provides the best advantage of gravity during delivery? Squatting. Rationale: A multiparous client is bearing down with contractions and crying out, "The baby is coming!" Which immediate action should the nurse implement? Visualize the perineum for bulging. Rationale: The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Shallow with an irregular rhythm. Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant. A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? Secretes both estrogen and progesterone. Rationale: What nursing action should be implemented when intermittently gavage-feeding a preterm infant? Allow formula to flow by gravity. Rationale: The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Shallow
with an irregular rhythm. Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant. The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement? Place the client in a side-lying position. Rationale: Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation? Pica. Rationale: When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? Count the heart rate for at least one full minute. Rationale: While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change? Fetal well being with labor progression. Rationale: An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding? The pinpoint spots are benign and disappear within 48 hours. Rationale: A client delivers her first infant and asks the nurse if her skin changes from pregnancy are permanent. Which change should the nurse tell the client will remain after pregnancy? Striae gravidarum. Rationale: A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? Ultrasonography. Rationale: A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light-headed, dizzy, and states that her fingers are tingling. What action should the nurse implement? Help her breathe into a paper bag. Rationale: The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? The nurse should first assess the infant's blood glucose level, because the infant is displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy demands. A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement? Document the findings in the client record. Rationale: While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? Cephalohematoma. Rationale: Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? Vitamin K (AquaMEPHYTON). Rationale: At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention? Uterine cramping. Rationale: A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? Respiratory rate of 11 breaths/minute. Rationale: A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding? 3.5 ounces. Rationale: Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? Exhibit interest in learning more about infant care. Rationale: What information should the nurse include about perineal self-care for a client who is 24-hours post delivery? Spray warm water from front to back using a squeeze bottle. Rationale: A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time? Observe interactions of family members with the newborn and each other. Rationale: While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding? Caput succedaneum. Rationale: The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment? Monitor for premature ventricular contractions. Rationale: A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next? Notify the healthcare provider. Rationale: A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? Abdominal ultrasound. Rationale: A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action? Intensity of contractions is 130 mm Hg. Rationale: A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first? Place the client in the knee-chest position. Rationale: When assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next? Document the finding as erythema toxicum. Rationale: A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, "Can I still breastfeed my baby?" What is the best response for the nurse to provide? Inform the client to continue breastfeeding. Rationale: The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide? Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. Rationale: A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake? Canned sardines. Rationale: What action should the nurse implement to prevent conductive heat loss in a newborn? Put a blanket on the scale when weighing the infant. Rationale: Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? Decrease in pulse rate. Rationale: A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur? The heart develops in the third to fifth weeks after conception. Rationale: The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? Give 10 liters of oxygen via face mask. Rationale: A client with asthma who is 8 hours post-delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer? Oxytocin (Pitocin). Rationale: A client in labor receives an epidural block. What intervention should the nurse implement first? Monitor blood pressure. Rationale: A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to baseline before each contraction ends. What action should the nurse implement? Document the finding in the client record. Rationale: Which finding in the medical history of a postpartum client should the nurse withhold the administration of a routine standing order for Methylergonovine?Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider.
Which prescription should the nurse administer to a newborn to reduce complications?Although (D) may be considered, it may not be the most therapeutic family-centered intervention when initially confronting the parents with the infant's prognosis. Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? Silver nitrate.
Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth?Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? B. By the third postpartum day, the new mother should start to take hold of caring for her infant, by asking questions about infant care and initiating care of her infant.
Which client should the nurse report to the healthcare provider as needing a prescription for RhoGAM?Which client should the nurse report to the health care provider as needing a prescription for RhoGAM? D) A primigravida mother who is rH negative.
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