Comprehensive Review for the NCLEX-PN EXAM Maternity

Comprehensive Review for the NCLEX-PN EXAM Maternity ScienceMedicineNursing HRHMCD Top creator on Quizlet Save Maternity and Pediatrics NCLEX PN ...38 terms cottonmollsPreview Maternity hesi prepared by me from...71 terms JustinLuitelPreview maternity notes 43 terms Mildredaug99Preview PN Mat 50 terms kay 20 minutes after a continuous epidural anesthetic is administered, a laboring clients blood pressure drops from 120/80 to 90/60 mmHG. What action should the practical nurse take immediately?

• notify the registered nurse or anesthesiologist
• continue to assess the blood-pressure q5 minutes
• place the client in a lateral position
• turn off the continuous epidural
• place the client in a lateral position

Rationale: placing a client in the lateral position and placing a pillow or wedge under one hip will deflect the uterus The total bilirubin level of a 36 hour, breast-feeding newborn is 14 mg/dL. Based on this finding, which intervention should the practical nurse implement?

• provide phototherapy for 30 minutes q8h
• Feed the newborn with sterile water hourly
• encourage the mother to breast-feed frequently
• assess the newborns blood glucose level
• encourage the mother to breast feed frequently

Rationale: breast milk provides calories and enhances G.I. motility, which will assist the bowel in eliminating bilirubin. The total bilirubin level is 6 to 12 mg/dL after day one of life. The infants bilirubin level is beginning to climb, and the infant should be monitored to prevent further complications.

A new mother is having trouble breast-feeding her newborn son. He's making frantic rooting motions and will not grasp the nipple. Which intervention should the practical nurse implement?

• encourage frequent use of a pacifier so that the infant becomes accustomed to sucking
• hold the infants head firmly against the breast until he latches onto the nipple
• encourage the mother to stop feeding for a few minutes and comfort the infant
• provide formula for the infant until he becomes calm and then offer the breast again
• encourage the mother to stop feeding for a few minutes and comfort the infant

Rationale: the infant is becoming frustrated and so is the mother; both need a timeout. The mother should be encouraged to comfort the infant and to relax herself. After such a timeout, breast-feeding is often more successful.Before discharge, what information should the practical nurse give to parents regarding the newborn's umbilical cord care at home?

• wash the cord frequently with mild soap and water
• Cover the cord with a sterile dressing
• allow the cord to air dry as much as possible
• apply baby lotion after the baby's daily bath
• allow the cord to air dry as much as possible

Rationale: recent studies indicate that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process The nurse is preparing a 3-day-old, full term newborn for discharge home. The baby's mother is HIV-positive. For which procedure should the practical nurse wear gloves? (Select all that apply)

• diaper changes
• obtaining vital signs
• formula feeding
• newborn hearing screening
• heel stick for metabolic screening
• discharge bath

A,E) diaper changes and heel stick for metabolic screening Rationale: after the infant has been given the admission bath, the PN should wear gloves only in those situations in which there is a potential for the presence of HIV positive blood and body fluids.The nurse is taking the temperature of a client who is 6 hours postpartum. The nurse notes that the clients temperature is 100.4°F. Which intervention should the nurse implement?

• encourage fluids to increase hydration
• recheck the temperature and 15 minutes
• place an ice pack on the clients forhead
• call the physician for an order for acetaminophen (Tylenol)
• encourage fluids to increase hydration

Rationale: it is normal for the postpartum client to have a temperature up to 100.4°F because of dehydration caused by labor. The most appropriate intervention is to encourage fluids to rehydrate the patient.

Which over-the-counter medication should the practical nurse recommend that a breast-feeding mother avoid?

• Famotidine (Pepcid)
• Ibuprofen (Motrin)
• acetylsalicylic acid (Aspirin)
• loratadine (Claritin)
• acetylsalicylic acid (aspirin)

Rationale: breast-feeding mother should avoid any products containing acetylsalicylic acid (aspirin) because of the possible association with reye syndrome and the infant.As part of the preoperative plan of care for a client who is scheduled for a repeat cesarean section, the practical nurse plans to administer the nonparticulate antacid sodium citrate by mouth. What is the purpose of administering this drug preoperatively?

• prevent postoperative nausea and vomiting
• raise the gastric pH to above 2.5
• improve gastric motility
• decrease the risk of aspiration
• raise the gastric pH to above 2.5

Rationale: sodium citrate is prescribed to increase the pH of gastric secretions and make them more alkaline so that if the client should vomit and aspirate, the chance of pneumonitis occurring is decreased.A client at 30 weeks gestation is complaining of pressure over the pubic area. At the clients admission to the antepartum unit for observation, vaginal examination shows that her cervix is closed, thick, and high. The fetal monitor reveals irregular contractions and underlying uterine irritability. Based on this information, which intervention should the practical nurse implement first?

• provide oral hydration
• encourage ambulation to stop contractions
• collect a specimen for urinalysis
• place the client on strict bed rest
• collect a specimen for urine analysis

Rationale: obtaining a urine analysis should be done first, because preterm clients with uterine irritability and contractions are often suffering from a urinary track infection and this should be ruled out first.When should the practical nurse encouraged a laboring client to begin pushing?

• at complete cervical effacement
• when the client describes the need to have a bowel movement
• at complete cervical dilation
• upon palpation of an interior or posterior lip of the cervix
• at complete cervical dilation

Rationale: pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm. If pushing begins before the cervix is completely dilated, the cervix can become edematous and may never completely dilate, necessitating an operative delivery.

The practical nurse caring for a laboring client encourages her to void at least q2h and records each time the client empties her bladder. What is the rationale for implementing this nursing intervention?

• emptying the bladder during delivery is difficult because of the position of the presenting fetal part
• an over-distended bladder could be traumatized during labor and could prolong the progress of labor
• urine specimens for glucose and protein must be obtained at certain intervals throughout labor
• frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection
• an over-distended bladder could be traumatized during labor and could prolong the progress of labor

Rationale: A full bladder can impair the efficiency of the uterine contractions and impede descent of the fetus during labor. Also, because of the close proximity of the bladder to the uterus, the bladder can be traumatized by the dissent of the fetus.The practical nurse is caring for a gravida 4, para 3 admitted to the antepartum unit in preterm labor at 32 weeks gestation. The client has previously been diagnosed with rheumatic heart disease. Which assessment findings indicate the onset of cardiac failure requiring immediate intervention?

• edema, basilar rales, and tachycardia
• increased urinary output and irregular heart rate
• shortness of breath, bradycardia, and hypertension
• regular heart rate and hypertension
• edema, basilar rales, and tachycardia

Rationale: edema, basilar rales, and and an irregular pulse indicate cardiac decompensation and require immediate intervention.A pregnant client is being discharged after presenting to the labor and delivery unit in false labor. The nurse explains to the client the signs of true labor. Which statement made by the client indicates that further teaching is required?

• "My contractions will not go away if I walk around."
• "My contractions will get stronger and closer together."
• "My contractions may feel like really bad menstrual cramps."
• "My contractions will be irregular and I will feel them in my abdomen."
• "My contractions will be irregular and I will feel them in my abdomen."

Rationale: false labor contractions are irregular, non-progressing, and usually felt in the abdomen or groin.What pulse is used to determine the presence of a pulse in the infant during cardiopulmonary resuscitation?Brachial pulse