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Maternal newborn 2
Terms in this set (20)
a client has a postpartum hemorrhage as a result of a cervical laceration. Which of the following assessment findings should the nurse expect to observe
continuous vaginal bleeding in the presence of a firm fundus
A nurse has just given a rubella vaccine to a client who is two days postpartum. Which of the following statements by the client should alert the nurse to the client's need for further instruction
I can conceive anytime I want after 10 days
A nurse caring for a client 14 hr after delivery assesses the following... Uterus slightly deviated to the right
Ask the client to empty her bladder
A nurse is about to administer methergine malate to a postpartum client. Which nursing assessment should be conducted prior to administration
A client who is primigravida delivers a newborn who is 7 pounds. The client states that she plans to breastfeed. 4 hours later, the client assesses the fundus is firm and deviated to the left. She has moderate luchia rubra and has voided 150 ml since delivery. The client asks for her infant. The nurses first action should be to
Palpate the client's bladder.
A nurse is caring for a client who has had a cesarian birth and is reporting abdominal distention. Which of the following actions should the nurse implement?
Suggest that the client ambulate in the hallway
A nurse is assessing a neonate born at 39 weeks of gestation. Which characteristic is the nurse most likely to find in this neonate?
Creases covering the entire bottom of both feet
While assessing a client who gave birth 1 week ago with an epidural block, the postpartum recovery room nurse discovers that the client has a saturated perineal pad within 20 minutes. Which of the following actions should the nurse conduct?
Massage the client's fundus
Which medication does the nurse need to administer to all newborn's within 1 hr after delivery?
Erythromycin ophthalmic (Ilotycin)
When assessing a newborn for congenital hip dysplasia, the nurse should be alert for?
limited abduction of one hip
When planning the care of a preterm newborn being discharged home with the use of an apnea monitor, the nurse should want the caregivers to give a return demonstration on which aspect of newborn care
A nurse is caring for a 3 day old infant receiving phototherapy for elevated bilirubin. A nursing action that would put the client at risk would be to...
Swaddle the infant to maintain body temperature
A nurse is caring for a postpartum client 8 hrs post delivery. Which of the following factors places the client at risk for postpartal atony?
Precipitous delivery, Distended bladder, Macrocosmic delivery
A nurse is assessing a newborn immediately after birth and makes these observations: Hr 136/min, Resp 36/min, vigorous cry, active movement and acrocyanosis. What is the apgar score?
A nurse on the postpartum floor is caring for a client on the day of delivery and assisted her out of bed for the first time. The client becomes frightened when she passes a blood clot and notices an increase in her lochia. Which information should the nurse include in an explanation of the client?
The blood pools in the vagina when you are lying in bed
While assessing a 2 day old infant, the nurse finds a soft spot on the left side of the infants head.
This will resolve in 2 to 6 weeks without treatment
A nurse is caring for neonates in the nursery. Which of the following neonates is at greatest risk for hypoglycemia?
Neonate who is large for gestational age
A nurse is testing a neonate's reflexes to assess neurologic maturity. Which reflex is the nurse testing by quickly and gently turning the neonates head to one side?
What should the nurse include in a postpartal plan for a client who does not plan to breastfeed?
Have the client place ice packs on her breasts
At 12 hr of age, an infants respiratory rate is 44/min. The respirations are shallow with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse conduct based on the assessment data?
Continue routine monitoring
THIS SET IS OFTEN IN FOLDERS WITH...
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