Newborn Obstetrical Nursing 308

1. A nurse is discussing possible side effects with a patient who recently received a prescription for combination oral contraceptives. Which of the following results calls for the client to inform the provider, according to the nurse’s instructions?
   Answer. Breathlessness
   Explanation. In the event that the client experiences dyspnea, the nurse should advise them to contact the provider right away. Chest pain and shortness of breath may be signs of a myocardial infarction or pulmonary embolus. In addition, the nurse ought to advise the patient to report any additional side effects—such as severe leg pain, abrupt or ongoing headaches, impaired vision, or abdominal pain—to the healthcare practitioner.
2. A nurse is tending to a patient after an amniocentesis performed at eighteen weeks of gestation. Which of the following results, if present as a potential problem, should the nurse notify the provider?
   Answer. Fluid seeping out of the vagina
   Explanation. This should be reported to the provider as it may be an early sign of amniotic fluid leakage.
3. A nurse is applying Nagele’s rule to determine the anticipated date of birth for a client. The patient informs the nurse that she began her most recent menstrual period on November 27. Which of the following is the anticipated birthdate of the client?
   Answer. September 3rd
   Explanation. The nurse should deduct three months from the start day of the client’s most recent menstrual cycle and then add seven days when applying Nägele’s rule to determine the client’s approximate date of birth. August 27th is equal to November 27th minus three months. Three days from August 27th is September 3rd.
4. A client who is 41 weeks pregnant and has a positive contraction stress test is being cared for by a nurse. Which diagnostic test does the client need to be ready for by the nurse?
   Answer: Biophysical profile (BPP)
   Explanation. In order to further evaluate the fetal well-being, the nurse should get the client ready for a BPP. If the contraction stress test comes out positive, uteroplacental insufficiency may be present. A BPP looks for fetal biophysical responses to stimuli and visualizes the physical and physiological features of the fetus using real-time ultrasound imaging.

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5. A new mom is being taught about newborn safety by a nurse. Which of the following guidelines ought to be part of the curriculum for the nurse?
   Answer. You can share your room with your baby for the next few weeks.
   Explanation. For the first several weeks, room sharing should be advised by the nurse. This enables the parent to become familiar with the newborn’s cues and be easily accessible to them. But since it raises the danger of SIDS, the nurse should advise the parent to refrain from putting the baby in their bed.
6. A client in labor with a fetus in the correct occiput posterior position is being attended to by a nurse. The client complains of back ache and has dilation to 8 cm. What course of action ought the nurse to follow?
   Answer. Put sacral counterpressure in response.
   Explanation. Sacral counterpressure should be applied by the nurse to help ease labor discomfort in the back that is associated with the fetal posterior position.
7. When a nurse examines a client who is in labor vaginally, she notices that the umbilical cord is sticking out of the vagina. Which of the following steps should the nurse take next after phoning for help?
   Answer. Using two gloved fingers, provide internal upward pressure on the part that is being shown.
   Explanation. Applying internal upward pressure to the presenting part is the first thing the nurse should do using evidence-based practice. Reduced perfusion to the fetus during labor due to prolapse of the umbilical cord may cause hypoxia. Once help has been summoned, the nurse should use two gloved fingers to provide upward internal pressure on the presenting part of the chord in order to release the compression. They shouldn’t move their hand, nurse.Newborn OBSTETRICAL NURSING 308.
8. A nurse is getting ready to give a postpartum client oxytocin. Which of the following results supports the recommendation to provide the medication? (SATA)
   Answer. The answer is indeed a flaccid uterus. The uterus becomes more contractile when oxytocin is present. Overdraft vaginal bleeding is accurate.
   Explanation. Because it increases uterine contractility, oxytocin reduces vaginal bleeding.
9. A nurse is explaining to a new mother what precautions the nurses would take to ensure her baby’s security and safety. Which of the following claims is appropriate for the nurse to make?
   Answer. The personnel that look after your child will have a badge with their photo on it.
   Explanation. To reassure the customer about the newborn’s safety, the nurse should inform them that all staff members who work with newborns must wear a picture identification badge. Staff personnel in certain units have unique badges or scrubs of a particular hue.
10. A nurse is evaluating the fetal heart tones of a pregnant client. The fetal position has been identified by the nurse to be left occipital anterior. Which part of the client’s belly should the nurse attach the ultrasound transducer to determine the fetus heart’s maximum intensity?
    Response: Lower left quadrant
    a) Left upper quadrant: This is where one can most easily hear the fetal heart tones of a fetus in the left sacral anterior position.
    b) Right upper quadrant: This is the finest place to hear the fetal heart tones of a fetus in the right sacral anterior position.
    c) Left lower quadrant: This is where one can most easily hear the fetal heart tones of a fetus in the left occipital anterior position.
    d) Right lower quadrant: This is where one can most easily hear the fetal heart tones of a fetus in the right occipital anterior position.
11. A nurse is demonstrating to a new mother how to suction her newborn’s secretions using a bulb syringe. Which of the following directions ought to be given by the nurse?
    Answer. Cease suctioning as soon as the baby’s cry is audible.
    Explanation. When the baby’s cry no longer seems to be coming through a bubble of fluid or mucus, the nurse should tell the client to stop suctioning.
12. A nurse is looking over a postpartum patient’s medical file who has preeclampsia. Which test findings from the list below should the nurse give to the provider?
    Answer. Platelets 50,000/mm3.
    Explanation. A platelet count of 50,000/mm3 may be indicative of disseminated intravascular coagulation since it is below the anticipated reference range. This outcome should be reported by the nurse to the provider.
13. Two hours after giving birth, a client is being cared after by a nurse. Which of the following interventions should the nurse prepare to carry out when postpartum behavioral adjustment is starting to take hold?
    Answer: Give the client a demonstration of how to give a baby bath.
    Explanation. During the taking-hold stage, the client is shown how to give a baby bath. The newly arrived parent transitions from being obedient to actively participating in her new duty as a mother. She is now concentrating on taking care of her infant and learning how to be a parent. During this time, the nurse should encourage the mother’s adjustment and instill confidence in the new parent.
14. A newborn assessment is being done by a nurse. Which of the following pictures represents spina bifida occulta, according to the nurse?
    Answer. The image appears to be of spina bifida occulta, which the nurse should recognize.
    Explanation. A dimpled area over the defect and the appearance of a birthmark or hairy patch above the area are external indicators of this neural tube abnormality.
15. Four clients are under the care of an antepartum unit nurse. Which of these patients needs to be the nurse’s top priority?
    Answer. Client who complains experiencing epigastric pain at 34 weeks gestation
    Explanation. When determining which client care is urgent versus nonurgent, the nurse should evaluate the patient if they report experiencing epigastric pain. An critical finding is that epigastric discomfort, a symptom of preeclampsia, implies hepatic involvement. This client should therefore be the nurse’s top focus.
16. A nurse is teaching a client with hyperemesis gravidarum about diet. Which of the client’s statements below best reflected their comprehension of the instruction?
    Answer. I’ll eat tasty food rather than trying to eat a balanced diet.
    Explanation. In order to prevent nausea, patients with hyperemesis gravidarum should consume foods they enjoy rather than attempting to eat a balanced diet.
17. At a routine prenatal visit, a nurse is assessing a client who is 30 weeks gestation. Which of the following conclusions is the nurse supposed to share with the provider?
    Answer. Face swelling is the response.
    Explanation. Facial, sacral, and finger swelling may be signs of preeclampsia or gestational hypertension. Retention of salt and water is caused by a decrease in renal perfusion. Edema is the result of fluid moving from the intravascular compartment into the tissues.
18. A nurse is examining a newborn to check for hypoglycemia symptoms. Which of the following results is the nurse likely to get?
    Answer. Jitteriness is the response.
    Explanation. Hypoglycemia is known to cause jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures. Hypoglycemia is more common in late preterm newborns and babies who are small or large for gestational age.

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19. A nurse is explaining terbutaline to a patient who is experiencing premature labor. Which of the client’s statements below best demonstrates that they have understood the lesson?
    Answer: I may experience a drop in potassium, so I will undergo blood tests.Newborn OBSTETRICAL NURSING 308.
    a) I’ll receive injections of the drug once a day until my labor ends.” – Terbutaline is injected subcutaneously every four hours for a maximum of twenty-four hours.
    b) While taking this medication, my blood sugar may be low.” – Hyperglycemia is a side effect of terbutaline.
    c) My potassium may drop, so I’ll get tested via blood.” – Hypokalemia is a side effect of terbutaline.
    d) During my medication, my blood pressure may rise.” – Hypotension is a side effect of terbutaline.
20. A nurse is organizing the care of a patient who is having an amniotomy and is in labor. Which assessment from the list below ought to be the nurse’s top priority?
    Answer. Temperature, in response
    Explanation. After an amniotomy, the biggest risk to a patient is infection. The client’s temperature should therefore be the nurse’s top priority when doing an assessment.
21. Three days after giving birth, a client of a nurse is scheduled for discharge. Which non-pharmacological intervention from the list below ought to be part of the nurse’s lactation suppression care plan?
    Answer: Rubbing the breasts with cabbage leaves.
    Explanation. Breast engorgement-related swelling and pain can be lessened by plant sterols and salicylates found in cabbage leaves.
22. A nurse is tending to a patient who stops responding when the placenta is delivered. Which of the following steps ought to be completed by the nurse first?
    Answer. Determine the respiratory system’s functionality.
    Explanation. When applying the airway, breathing, and circulation approach to client care, the nurse’s first priority should be to assess the patient’s respiratory status and whether cardiopulmonary resuscitation is necessary.
23. A client with pregestational type 1 diabetes mellitus is being taught pregnancy management by a nurse. Which of the client’s statements below best demonstrates that they have understood the lesson?
    Answer: If I feel queasy or throw up, I’ll keep taking my insulin.
    Explanation. It is recommended that the nurse instructs the client to adhere to her insulin prescription during illness in order to avoid episodes of hypo- and hyperglycemia.
24. After a circumcision, a newborn is being evaluated by a nurse. Which of the following observations suggests that the baby is in pain, according to the nurse?
    Answer. Spinning chin
    Explanation. When a newborn is in pain, their body will react with facial expressions like chin quivering, grimacing, and brow furrowing.
25. A client’s adjustment to pregnancy is being evaluated by a nurse in the antepartum clinic. The client claims to be “happy one minute and crying the next.” Based on the client’s statement, the nurse should determine which of the following is true?
    Answer. Emotional instability
    Explanation. The client’s statement should be recognized by the nurse as an indication of emotional lability. During pregnancy, many clients report experiencing abrupt and erratic shifts in their mood. During pregnancy, mood swings may be caused by intense hormonal changes. For little or no reason at all, feelings of joy or cheerfulness alternate with tears and anger.
26. A client seeking an oral contraceptive is being attended to by a nurse at a family planning clinic. Which of the following findings in the patient’s health history should the nurse consider an oral contraceptive contraindication? (SATA) Cholecystitis is accurate: Using oral contraceptives is prohibited if a patient has a history of gallbladder disease.
    a) It is true that high blood pressure prohibits the use of oral contraceptives.
    b) Misinformation about human papillomavirus: Using oral contraceptives is not prohibited in the presence of human papillomavirus.
    c) Yes, migraine headaches are accurate. Using oral contraceptives is contraindicated if you have a history of migraine headaches. It is incorrect to say anxiety disorder. Using oral contraceptives is not prohibited in the presence of an anxiety disorder.
27. An adolescent is being taught about levonorgestrel contraception by a school nurse. Which of the following details ought to be included in the instruction by the nurse?
    Answer. You should take the medication no later than 72 hours after engaging in unprotected sexual activity.
    Explanation. In order to prevent conception, levonorgestrel is an emergency contraceptive that inhibits ovulation. The teenager should be advised by the nurse to take this medication as soon as possible, no later than 72 hours following unprotected sexual activity.
28. Parents of a newborn are receiving discharge education from a nurse regarding the use of car seats safely. Which of the following directions ought to be given by the nurse?
    Answer. The retainer clip should be positioned so that it is level with the newborn’s armpits.
    Explanation. The baby should be placed in a car seat that has received federal approval and has the retainer clip snugly placed at the level of the baby’s armpits, per the nurse’s instructions to the parents.
29. A client with preeclampsia is being cared for by a nurse and is on an IV magnesium sulfate infusion that never stops. What course of action ought the nurse to follow?
    Answer. The nurse needs to have easy access to calcium gluconate.
    Explanation. In order to prevent cardiac or respiratory arrest in the event that the client experiences magnesium toxicity, the nurse should have calcium gluconate on hand.
30. A nurse getting ready to give a client a Leopold maneuver. Decide which order the nurse should go in. (Use all the steps and move them into the box on the right, arranging them according to performance.)
    Answer. When executing Leopold maneuvers, the nurse should palpate the client’s fundus to determine the fetal component.
    Explanation. The nurse should next ascertain the fetal back’s location. Third, the nurse needs to feel for the fetal component that is visible at the inlet.
    Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.
31. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?
    Answer: Massage the client’s fundus.
    Explanation. The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client’s fundus to expel clots and promote contractions.Newborn OBSTETRICAL NURSING 308.
32. A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?

Answer: Just above the symphysis pubis
Explanation. At the end of the first trimester of pregnancy, the client’s uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.

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33. A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching?
    Answer: You will be offered orange juice to drink during the test.
    Explanation. A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results.
34. A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
    Answer: Instruct the client to press the provided button each time fetal movement is detected.
    Explanation. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.
35. A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
    Answer: “You can miss your period for several other reasons. Describe your typical menstrual cycle.”
    Explanation. Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client’s menstrual cycle to determine other necessary interventions.
36. A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. What course of action ought the nurse to follow?
    Answer: Explain to the client this is an expected occurrence.
    Explanation. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.
37. A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
    Answer: Headache that is unrelieved by analgesia
    Explanation. A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.
38. A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following claims is appropriate for the nurse to make?
    Answer: Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.
    Explanation. Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor.
39. A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following steps ought to be completed by the nurse first?
    Answer: Verify the newborn’s identification.
    Explanation. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn’s identity upon arrival to the nursery.
40. A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, “What effects will this procedure have on my sex life?” Which of the following statements should the nurse make?
    Answer: “This procedure should have no effect on your sexual performance or adequacy.”
    Explanation. The nurse is giving the client the information she is seeking. Sexual function depends on several hormonal and psychological factors. Therefore, tubal blockage should have no physiological effect on sexual function.Newborn OBSTETRICAL NURSING 308.
41. A nurse is caring for a client who is experiencing premature labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medicine administration?
    Answer: “This medication stimulates fetal lung maturity.”
    Explanation. The nurse should advise the client that betamethasone is a glucocorticoid that increases fetal lung maturity by stimulating the production of enzymes that release lung surfactant.
42. A nurse is offering discharge training to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider?
    Answer: Unilateral breast pain
    Explanation. Sudden onset of chills, fever, malaise, body pains, headaches, and unilateral breast soreness can be signs of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider.
43. A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following action should the nurse take?
    Answer: Initiate continuous external fetal monitoring.
    Explanation. The nurse should determine that a pt who has a placenta previa and is actively bleeding is at an elevated risk for premature labor and hemorrhage. The nurse should initiate measures such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory levels. Also, the nurse should implement actions to prepare for an emergency birth.
44. A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following results is the nurse likely to get?
    Answer: Decreased platelet count
    Explanation. A client who has ITP has an autoimmune reaction that results in a reduced platelet count.
45. A nurse is analyzing the laboratory findings for a client who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse mention to the provider?
    Answer: Hemoglobin 10 g/dL
    Explanation. A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this laboratory finding to the provider.
46. A nurse is reading the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions?
    Exhibit 1: Diagnostic Results Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absentABO-Rh B-negative Exhibit 2: Medication Administration Record – Terbutaline 0.25 mg SQ every hr PRN contractions Rho(D) immune globulin 300 mcg IM once Nalbuphine 10 mg IV every 3 hr PRN discomfort
    Exhibit 3: Progress Report – 1655 – Amniocentesis completed, to transducer and external fetal monitor applied 1700 – Fetal heart rate 130/min with moderate variability Uterine contractions q 5 to 8 min lasting 30 to 60 sec duration Uterine contractions palpated at 1+ intensity Client reports uterine contraction pain of 2 on a scale of 0 to 10
    Answer: Administer terbutaline.
    Explanation. The nurse should inject terbutaline to stop contractions because the test results indicate that the fetus’s lungs are not mature enough for birth.
47. A nurse is analyzing laboratory results of a newborn who is 4 hr old. Which of the following conclusions is the nurse supposed to share with the provider?
    Answer: Bilirubin 9 mg/dL
    Explanation. A bilirubin level of 9 mg/dL is over the expected reference range for a newborn who is 4 hr old. The predicted reference range for a newborn that is less than 24 hours old is 2 to 6 mg/dL. The nurse should report this finding to the provider.
48. A nurse is studying the test report of a newborn who is 24 hr old. Which of the following results should the nurse communicate to the provider?
    Answer: Blood glucose 30 mg/dL
    Explanation. Newborns less than 24 hours old should have a blood glucose of 40 to 60 mg/dL. Newborns that are greater than 24 hours old should have a blood glucose of 50 to 90 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a baby who is 24 hr old and should be reported to the provider.
49. A nurse is offering training about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?
    Answer: You should leave the diaphragm in place for at least 6 hours following intercourse.
    Explanation. The client should maintain the diaphragm in place for at least 6 hr following intercourse to provide protection against pregnancy. Newborn OBSTETRICAL NURSING 308.
50. A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the client’s statements below best reflected their comprehension of the instruction?
    Answer: I will need this medication if I have an amniocentesis.
    Explanation. Rho(D) immune globulin is provided to clients who are Rh negative following an amniocentesis because of the likelihood of fetal RBCs entering the maternal circulation.
51. A nurse is checking the medical record of a recently admitted client who is at 32 weeks of gestation. Which of the following circumstances is an indication for prenatal assessment using electronic fetal monitoring?
    Answer: Oligohydramnios
    Explanation. The nurse should determine that oligohydramnios warrants further fetal screening using electronic fetal monitoring. Other disorders that require further investigation include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, past fetal mortality, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.
52. A nurse is caring for a client who is in labor and notes increased rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should determine that the client is in which of the following phases of labor?
    Answer: Transition
    a) Active -The active phase of labor is characterized by a cervical dilation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds.
    b) Transition – The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilation of 8 to 10 cm with contractions every 2 to 3 min, each lasting 45 to 90 seconds.
    c) Latent – The latent phase of labor is characterized by cervical dilatation of 0 to 3 cm with contractions every 5 to 30 min, each lasting 30 to 45 seconds.
    d) Descent – The descent phase of labor is marked by aggressive pushing with contractions every 1 to 2 min, each lasting for 90 seconds.
53. A nurse is assessing a newborn who is 12 hr old. Which of the following signs demands action by the nurse?
    Answer: Substernal chest retractions when sleeping
    Explanation. Substernal chest retractions can suggest respiratory distress syndrome in the infant. This symptom requires additional assessment and action by the nurse.
54. A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?
    Answer: A blood glucose of 130 to 140 is considered a positive screening result.
    Explanation. The nurse should advise the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client has a positive result, she will need to undertake a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.

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55. A nurse is assessing a client who gave birth vaginally 12 hours ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
    Answer: Assist the customer to empty her bladder.
    Explanation. The nurse should assist the client to empty her bladder because the evaluation findings show that the client’s bladder is swollen. This can inhibit the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.
56. A nurse in a women’s health clinic is offering teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should counsel the client to boost her daily consumption of which of the following nutrients?

Answer: Iron
Explanation. The guideline for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old. Newborn OBSTETRICAL NURSING 308.

57. A nurse is preparing care for a client who is in labor and is asking epidural anesthesia for pain relief. Which of the following actions should the nurse include in the plan of care?
    Answer: Monitor the client’s blood pressure every 5 min following the first dosage of anesthetic solution.
    Explanation. The nurse should prepare to acquire a baseline blood pressure prior to the commencement of anesthetic solution. The nurse should then continue to monitor the client’s blood pressure every 5 to 10 min to assess for maternal hypotension produced by the anesthetic solution.

58. A customer who used selective serotonin reuptake inhibitors (SSRIs) during her pregnancy is having her newborn evaluated by a nurse. Out of the following symptoms, which one should the nurse recognize as a sign of stopping an SSRI?
    Answer. Regurgitating
    Explanation. Frequent signs and symptoms linked to SSRI exposure in utero include restlessness, agitation, tremors, diarrhea, and vomiting. Usually, these symptoms persist for two days.

59. A infant being treated for hyperbilirubinemia with phototherapy is under the care of a nurse. What course of action ought the nurse to follow?
    Answer. The newborn’s eyes should be shielded from the phototherapy light.
    Explanation. By using an opaque eye mask, the phototherapy light can’t harm the newborn’s cornea and retina.