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. “Moststerilization 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

4. “You will receive an antacid containing magnesium before the medication”

-uterine stimulant. Controls postpartum hemorrhage. Assess uterine tone and vaginal

bleeding

-postpartum hemorrhage nursing care: massage fundas. Insert urinary catheter to assess

kidney functions to obtain accurate urinary output for bladder distention. Elevate legs.