1. A nurse is performing an initial assessment of a newborn who was delivered

with a nuchal cord. Which of the following clinical findings should the nurse

expect?

Facial petechiae- seen over the presenting part with soft tissue injuries

-nuchal cord: umbilical cord around fetal neck. Will cause variable deceleration

of FHR. Intervention: repositi on client from side to side or into knee chest,

discontinue oxytocin if being infused, oxygen

2. A nurse is monitoring a newborn whose mother reports recent opiate use for

neonatal abstinence syndrome. Which of the following findings indicates narcotic

withdrawal?

1. Respiratory rate 50/min

2. Unequal pupils

3. Hypotonia

4. Excessive crying

• Substance withdrawal in the newborn occurs when the mother uses drugs

during pregnancy.

• Hitch pitch shrill cries, incessant crying, tremors, increae deep tendon

reflexes, disturbed sleep pattern, hypertonicity, convulsions

• Nasal congestion w/ flaring, apnea, tachypnea <60>

3. A nurse is caring for a client who is in the second stage of labor. The nurse

observes the fetal head retract against the clients perineum immediately

following emergence . Which of the following actions should the nurse take?

1. Assess fetal position using Leopold maneuvers

2. Reposition the client in a left lateral position??? Not sure

3. Apply pressure to the clients suprapubic area

4. Empty the client’s bladder using Crede’s maneuver

• Pg 189) Prepare to apply suprapubic pressure to aid in the delivery of

the anterior shoulder, which is located inferior to the maternal

symphysis pubis.

4. A client and her partner ask the nurse for information about permanent

contraception. Which of the following statements should the nurse include in

the counseling?

1. “A man is usually sterile immediately after a vasectomy”- must use birth

control after procedure. Is not effective until 20 ejaulations or 1 week to

several months to allow all sperm to clear

2. “The menstrual cycle is shorter after a tubal ligation”

3. “Most sterilization procedures are considered irreversible”

4. “A woman should use contraception for 1-2 months after a tubal ligation”

5. A nurse is providing education to a client who is to receive misoprostol for

induction of labor. Which of the following instructions should the nurse include

in the teaching?

1. “ I will insert a urinary catheter before I administer the medication” -??

2. “I will begin an oxytocin infusion w/in 2 hrs of your last dose of medication”

3. “You will like on your side for 40 minutes after I administer the medication