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 reportsrecent 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 isin 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. Assessfetal position using Leopold maneuvers

2. Reposition the client in a left lateral position??? Notsure

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 anteriorshoulder, 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 statementsshould

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 forinduction 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 yourside 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 functionsto obtain accurate urinary

output for bladder distention. Elevate legs.

6. A nurse is assessing a client who isin hersecond trimester for common physiological changes during pregnancy. The nurse notes a

blotchy discoloration on the client’s forehead, nose & cheeks. Which of the following changes should the nurse document p. 17

chapter 3

1. Linea nigra-dark line pigmentation from umbilicusto the pubic area.

2. Epulis- not found on ati book, but it is a tumor on the mouth caused by gingervitis.

3. Striae gravidarum - stretch marksfound on abdomen and thigh

4. Chloasma -increase pigmentation on the face

7. A charge nurse is discussing STIs w/ a newly licensed nurse. Which of the following infectionsshould the nurse include in the

teaching as an indication for a cesarean birth p . 50 ch 8

1. Gonorrhea- spread genital to genital

2. Chlamydia

3. HIV

4. Syphilis

- INDICATIONS for C-Section

::::::: Malpresentation, Non-reassuring fetal heart tones