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Terms in this set (36)The nurse providing culturally sensitive care to a group of new of mothers should reinforce information concerning breast feeding to which client? 1. Mother of African descent who wants to breastfeed for 2 years 4. Mother of Hispanic descent who refuses to offer colostrum to the newborn The nurse is monitoring a neonate 1 hours after spontaneous vaginal delivery. Which of the following are expected findings? SATA 1. Capillary glucose of 60 mg/dL 1, 3, 5. Glucose levels should be < 70-100 Reinforcing teaching about breast feeding to a postpartum client: which state by the client indicates a correct understanding of teaching? 1.
"I will feed my baby for 5-10 minutes on each breast" 3. "If i need to reposition my baby's latch, I will use my finger to break the suction first" The nurse is caring for a newborn at term gestation during the first two hours following vaginal birth. Which of the following interventions should the nurse implement during this time? SATA 1. Apply 0.5% erythromycin ophthalmic ointment 1, 4, 6 The PN is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the RN? 1. Discomfort during fundal palpation 2. Foul smelling lochia r/t endometrial infection The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer? 1. Acetaminophen PO PRN for fever 2. Clindamycin IV every 8 hour The nurse is evaluating a client's understanding of postcircumcision care for a 24 hour old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching? 1. "Bleeding should be no larger than the size of a quarter" 4. "Yellow exudate on the glans penis indicates infection" A client with poorly controlled DM gives birth to a newborn at term gestation. When caring for the 2 hour old newborn, which clinical finding requires the nurse to intervene? 1. Cyanosis of hands and feet 3. Jitteriness The PN is assisting the RN to care for a 6 hour old term newborn of a mother with GDM. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL/ The newborn is asymptomatic. Which intervention should the PN anticipate implementing first? 1. Feed the newborn 1. Feed the newborn PN is assisting with care for 1 day old client who is irritable, feeing poorly, and only sleeping for very short intervals. The newborn's mother has been taking hydrocodone on a regular basis for several years. When collaborating with the RN to develop a POC, which intervention should the PN include? 1. Avoid giving the newborn a pacifier 4. Swaddle and gently rock the newborn Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching? 1. "I
should avoid resuming sexual intercourse until after my vaginal bleeding has stopped" 3. "I will begin using condoms to prevent pregnancy once menses returns." The nurse is monitoring a newborn with skin discoloration in the lumbar area. Which action by the nurse is appropriate? 1. Check the infant's hgb, hct, and platelet levels 2. Measure and document the size and location of the markings Mongolian spots are often seen in newborns of ethnicity with darker skin tones The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching? 1. "I can expect the cord to turn black in a few days" 4. "I will secure the diaper over the cord to protect it" A client postpartum 3 days scheduled for discharge today was given education about diaper changes yesterday. The client says to the nurse, "I'm so glad you are here. I think my baby has a dirty diaper. I can't change it as well as you can. Will you change my baby's diaper for me?" What is the nurse's best response? 1. Reassure the mother that it takes tie to learn how to care for a bay while quickly changing the diaper 2. Suggest that the mother change the diaper as the nurse watches The nurse is performing postdelivery care of a newborn delivered 35 weeks gestation. Which of the following actions by the nurse are appropriate? SATA 1, 2, 3. Find measure to keep newborn warm The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up? 1. Edema of the scalp crossing the suture lines 3. Small tuft of hair at the base of the spine r/t spina bifida The nurse is reinforcing instructions to a parent about how to care for a newly circumcised newborn. Which statement by the parent indicates a need for further teaching? 1. "Discharge and odor indicate infection of the circumcision site." 2. "I will clean the area with alcohol based wipes or soap water" An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? SATA 1. Angle bottle up and toward cleft 2, 3, 5 A nurse is caring for a postpartum client who has breast engorgement following breastfeeding. Which instructions should the nurse reinforce regarding relief of breast engorgement? 1. Allow newborn to nurse for at least 10-15 min on each breast 1. Allow newborn to nurse for at least 10-15 min on each breast Continue breastfeeding, don't pump breasts between feedings, apply warm/cold compress, take warm showers, use anti-inflammatory analgesics A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first? 1. Administer 10 units of oxytocin IM 3. Assist the client to void on a bedpan A woman who had a cesarean delivery 5 hours ago now appears anxious and reports SOB. The PN should assess for which priority problem before notifying RN? 1. Calf warmth and redness 1. Calf warmth and redness r/t risk for thrombus formation and DVT
The nurse observing a student nurse care for a mother who had been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene? 1. Assesses the baby's position and sucking behavior during breastfeeding 3. Provides supplemental formula feedings until improved breastfeeding occurs The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk has a pink color. What is the nurse's initial action? 1. Apply oxygen and count respiration 4. Place infant skin to skin with mother The nurse preceptor should intervene if the graduate PN performs which action when caring for a jaundiced newborn being treated with phototherapy? 1. Allowing the parents to feed the newborn 2. Applying a shirt while the newborn is exposed to phototherapy A nurse is reinforcing information on formula preparation for a client with a newborn. Which statements by the client indicate proper understanding? SATA 1. "I can add water to the formula if my baby wants to eat more frequently" 2, 5. A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation? 1. "I feel so exhausted that i started taking naps when
the baby sleeps" 3. "My aunt has come over every day to care for the baby because the baby's cries bother me." The nurse reinforcing discharge instructions to a postpartum client. Which instruction should the nurse include to promote newborn safety? 1. Avoid using blankets to position the infant in the car seat 4. Remove pillows and loose blankets from the infant's crib The PN is assisting with care for several newborn in the nursery. Which of the following findings are abnormal and need to be reported to the RN? SATA 1. Chest wall retractions 1, 4, 5 Abnormal respiratory effort is a sign of respiratory distress The nurse is performing an assessment on a 39 week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? SATA 1. One artery and one vein in the umbilical cord 2, 4, 5 Multiple plantar creases, babinski reflex, epstein pearls A nurse is reinforcing teaching to a breastfeeding client who has been diagnosed with mastitis of the right breast. Which instructions should be included? SATA 1. Cease breastfeeding from right breast 2, 4 Tx for lactational mastitis: abx therapy, correct breast support, adequate hydration, analgesics and frequent continued breastfeeding (every 2-3 hours) A nurse is monitoring a newborn. Which of the following clinical findings should the nurse recognize as expected? SATA 1. Cyanosis
of the hands and feet 1, 3 The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk for postpartum hemorrhage? 1. Infant birth weight of 9 lb 2 oz 1. Infant birth weight of 9 lb 2 oz The nurse is reinforcing teaching about infant safety to a class of expectant parents. Which statement by a participant indicates a need for further instruction? 1. "I will make sure there is a firm mattress in the crib" 3. "I will tie bumper pads to the sides of the crib to protect my baby's head" risk for SID A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention? 1. Lochia that soaks a perineal pad every 2 hours 2. Persistent headache with blurred vision r/t postpartum preeclampsia A newborn is seen in the ER for vomiting. Which assessment finding indicates a possible emergency? 1. Frequent vomiting since
birth 3. Vomit that is green A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? SATA 1. Irritability and restlessness 1, 4, 5. Sets found in the same folder363 terms jamesoribhabor maternity uworld75 terms ManukMacy NCLEX77 terms erinhopesholty UWorld Child Health150 terms Anne_S75 Other sets by this creatorLeadership/Management: Delegation & Prioritization26 terms Yunyun_Lin2 Maternity: Antepartum, L&D46 terms Yunyun_Lin2 Labs nclex preparation (Renee_Camarena)34 terms Yunyun_Lin2 Other Quizlet setsState Law B25 terms brittneyAgraham The United States Constitution - Article 162 terms marisa_nicole Ep US History Fall Exam Mr. Ross63 terms ethanzager122 pkt 9, 10, 11, 1277 terms chy-chy-cha-cha Related questionsQUESTION The client is admitted to the labor suite complaining of pain less vaginal bleeding. The nurse assist with the examination of the client, knowing that which routine labor procedure is contraindicated? 3 answers QUESTION What is the BMI for someone who is overweight 15 answers QUESTION What does the sympathetic stimulation do to the pulse? 10 answers QUESTION The nurse receives a call from the laboratory with some lab values. Which lab value represents the highest priority for the nurse? 2 answers How should a nurse screen the newborn of a mother with diabetes for hypoglycemia?Newborns at risk for hypoglycemia should have a blood test to measure blood sugar level frequently after birth. This will be done using a heel stick. The health care provider should continue taking blood tests until the baby's glucose level stays normal for about 12 to 24 hours.
How would the nurse explain the cause of caput Succedaneum in a newborn to the new mother?Again, caput succedaneum is caused by external pressure or force on the baby's head during delivery which ruptures small blood vessels beneath the scalp. This pressure can simply be caused by passing through the birth canal or the result of delivery assistance tools such as vacuum extractors or forceps.
Which factor contributes to the development of physiological jaundice in a newborn?Excess bilirubin (hyperbilirubinemia) is the main cause of jaundice.
Why is breastfeeding not always possible?Hypoplasia of the breast, also known as insufficient glandular tissue or IGT, occurs when the mammary tissue and glands don't develop normally. Women with this rare condition often have breasts that don't produce enough milk to nurse exclusively.
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A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation
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