Question

A nurse is planning care for a newborn who is large for gestational age. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Answer 1

Correct Answers:

Check the newborn's skin for ecchymosis.
Assist the mother to breastfeed the newborn after birth.
Check the newborn's blood glucose level.

Rationale :

👶 Check the newborn's skin for ecchymosis

👶 A newborn who is large for gestational age (LGA) is at increased risk for birth trauma due to larger body size during delivery.

👶 The nurse should assess for ecchymosis, bruising, clavicle injury, soft tissue injury, and signs of difficult birth.

👶 Trauma can occur from shoulder dystocia or prolonged labor.

👶 Early identification supports prompt treatment and monitoring.

👶 A thorough physical assessment is an important priority after birth.

👶 Assist the mother to breastfeed the newborn after birth

👶 LGA newborns have an increased risk for hypoglycemia, especially if maternal diabetes was present.

👶 Early feeding provides glucose and helps stabilize neonatal blood sugar levels.

👶 Breastfeeding should begin as early as possible after birth if the newborn is stable.

👶 Frequent feeding supports metabolic adaptation and prevents complications.

👶 Nurses should monitor feeding effectiveness and tolerance.

👶 Check the newborn's blood glucose level

👶 Hypoglycemia is one of the most common complications in LGA newborns.

👶 Increased insulin production before birth may continue after delivery and lower glucose levels.

👶 Signs of hypoglycemia include jitteriness, poor feeding, weak cry, lethargy, and temperature instability.

👶 Blood glucose monitoring allows early intervention.

👶 Timely detection prevents neurologic complications.

❌ Obtain a stool sample of meconium

❌ Routine meconium sampling is not indicated specifically because a newborn is LGA.

❌ Meconium evaluation is performed only for specific clinical indications.

❌ Assist with administering a blood transfusion to the newborn

❌ Blood transfusion is not routine care for an LGA newborn.

❌ Assessment and glucose stabilization are higher priorities.

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Answer 2

Correct Answers:

Epigastric pain

Rationale :

🚨 In a client who is 28 weeks pregnant with preeclampsia, epigastric pain is the priority finding because it may indicate severe preeclampsia and liver involvement.

🚨 Epigastric or right upper quadrant pain can occur due to hepatic ischemia, liver capsule stretching, or progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets).

🚨 This finding may precede seizures (eclampsia), liver rupture, placental compromise, or maternal deterioration and requires immediate evaluation.

🚨 The nurse should promptly assess additional severe features such as headache, visual disturbances, hyperreflexia, decreased urine output, and fetal status.

🚨 Maternal stabilization and provider notification take priority.

❌ Blood pressure 146/92 mm Hg

❌ This blood pressure meets criteria for hypertension in pregnancy but is not the most urgent finding presented.

❌ Severe features and end-organ symptoms take higher priority.

❌ Ankle edema

❌ Mild edema may occur during pregnancy and is not the most concerning finding in preeclampsia.

❌ It is less predictive of severe disease progression.

❌ 1+ proteinuria

❌ Proteinuria supports the diagnosis of preeclampsia but does not indicate immediate deterioration by itself.

❌ Epigastric pain suggests more severe involvement.

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Answer 3

Correct Answers:

Tetracycline

Rationale :

🤰 Tetracycline is contraindicated during pregnancy because it crosses the placenta and can harm fetal development.

🤰 Exposure may cause permanent discoloration of fetal teeth, impaired bone growth, and effects on skeletal development.

🤰 Tetracyclines are generally avoided during pregnancy, especially during the second and third trimesters due to fetal risks.

🤰 In a pregnant client with syphilis, the recommended treatment is penicillin therapy, as it effectively treats both the mother and helps prevent congenital syphilis.

🤰 Nurses should reinforce completing treatment and ensuring follow-up testing.

❌ Ceftriaxone

❌ Ceftriaxone is not the contraindicated medication in pregnancy in this scenario.

❌ It may be used for selected infections under provider guidance.

❌ Benzathine penicillin G

❌ Benzathine penicillin G is the treatment of choice for syphilis during pregnancy.

❌ It is the preferred therapy to reduce fetal transmission.

❌ Azithromycin

❌ Azithromycin is not the standard treatment for syphilis in pregnancy but is not the contraindicated option here.

❌ Penicillin remains preferred.

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Answer 4

Correct Answers:

Apply two identification bands to the newborn's extremities.

Rationale :

👶 Immediately after birth, newborn identification is a high-priority safety intervention to prevent infant misidentification and ensure correct matching with the parent.

👶 The nurse should apply two identification bands to the newborn’s extremities (commonly the wrist and ankle) according to facility policy.

👶 Identification bands are applied as soon as possible after birth and before separation from the parent.

👶 The information on the bands must match the mother’s identification information to ensure safe care and newborn security.

👶 Nurses should verify identification during assessments, procedures, feedings, and transport.

❌ Footprint the newborn prior to applying an identification band.

❌ Footprints may be obtained according to facility policy but are not completed before immediate identification procedures.

❌ Identification bands are applied first to establish identity promptly.

❌ Transport the newborn to the nursery to apply the identification band.

❌ Identification should occur in the birthing area before transport or separation from the parent.

❌ Delaying identification increases risk of newborn identification errors.

❌ Check that the identification band label includes the newborn's weight.

❌ Identification bands generally focus on matching identifiers rather than newborn weight.

❌ Weight is documented in the health record but is not the key identification element.

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Answer 5

Correct Answers:

11.4 to 15.9 kg (25 to 35 lb)

Rationale :

🤰 A prepregnancy BMI of 21 falls within the normal BMI range (18.5–24.9).

🤰 For clients with a normal BMI before pregnancy, the recommended total pregnancy weight gain is 11.4 to 15.9 kg (25 to 35 lb).

🤰 Appropriate weight gain supports normal fetal growth, placental development, maternal nutritional needs, and healthy pregnancy outcomes.

🤰 Insufficient weight gain may increase the risk of fetal growth restriction and low birth weight, while excessive gain may increase the risk of gestational hypertension, gestational diabetes, and delivery complications.

🤰 Weight gain should occur gradually, with increased nutritional intake focused on balanced nutrition rather than excess calories.

❌ 16.4 to 20.5 kg (36 to 45 lb)

❌ This range is generally recommended for clients who are underweight before pregnancy (BMI <18.5).

❌ A BMI of 21 does not require this amount of gain.

❌ 8.2 to 10.9 kg (18 to 24 lb)

❌ This amount is lower than recommended for a normal prepregnancy BMI.

❌ Such ranges are more consistent with overweight pregnancy recommendations.

❌ 5 to 7.7 kg (11 to 17 lb)

❌ This lower weight gain recommendation is typically associated with obesity in pregnancy.

❌ It would not be appropriate for a client with BMI 21.

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Answer 6

Correct Answers

Blank 1 Correct Option: FHR
Blank 2 Correct Option: Contraction pattern
Blank 3 Correct Option: amniotic fluid characteristics

Rationale :

🍼 FHR

🍼 The fetal heart rate (FHR) is the most important indicator of fetal oxygenation during labor.

🍼 This client is showing late decelerations, where the FHR drops after the contraction begins and returns to baseline after the contraction ends.

🍼 Late decelerations suggest uteroplacental insufficiency, meaning the fetus may not be receiving enough oxygen during contractions.

🍼 The baseline returns to 150/min, but repeated drops to 103–108/min are concerning and require close monitoring.

🍼 Continued FHR monitoring helps detect worsening fetal distress, prolonged decelerations, or need for urgent intervention.

🍼 Contraction pattern

🍼 The nurse should monitor the frequency, duration, and uterine resting tone of contractions because abnormal contractions can reduce fetal oxygenation.

🍼 This client’s contractions are occurring every 5 to 6 minutes and lasting 55 to 60 seconds, with uterine tone described as firm.

🍼 If contractions become too frequent, too long, or the uterus does not relax well between contractions, fetal oxygen exchange can decrease.

🍼 Adequate uterine relaxation between contractions allows blood flow to return through the placenta.

🍼 Monitoring the contraction pattern helps determine whether uterine activity is contributing to the late decelerations.

🍼 Amniotic fluid characteristics

🍼 The amniotic fluid changed from clear fluid to thin green fluid, which indicates meconium-stained amniotic fluid.

🍼 Meconium may occur when the fetus experiences stress or hypoxia before or during labor.

🍼 Green fluid increases concern for possible fetal compromise and risk for meconium aspiration after birth.

🍼 The nurse should continue assessing the amount, color, odor, and consistency of the fluid.

🍼 Changes in amniotic fluid provide important clues about fetal well-being and possible labor complications.

❌ Blood pressure

❌ The client’s blood pressure remains stable, ranging from 124/72 to 128/74 mm Hg, so it is not the main indicator of the current complication.

❌ Blood pressure should still be monitored routinely, but the urgent concerns are fetal status, uterine activity, and fluid changes.

❌ Pain level

❌ The pain level increased only from 4/10 to 5/10, which is expected as labor progresses.

❌ Pain does not explain the late decelerations or green amniotic fluid.

❌ Oxygen saturation

❌ The client’s oxygen saturation remains acceptable at 95–98% on room air.

❌ Maternal oxygenation should be monitored, but fetal tracing and meconium-stained fluid are more directly related to the complication.

❌ IV site

❌ The IV site is important for fluid and medication access, but it does not identify the current fetal labor complication.

❌ No signs of IV infiltration or malfunction are provided.

❌ Cervical dilation

❌ Cervical dilation helps assess labor progress, but it does not directly explain late decelerations or meconium-stained fluid.

❌ The priority is fetal response to labor and possible fetal compromise.

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Answer 7

Correct Answers:

Insert a straight catheter for the client.
Administer methylergonovine 0.2 mg IM.

Rationale :

✅ Insert a straight catheter for the client

🩸 The deviated, elevated fundus strongly suggests bladder distention, preventing the uterus from contracting effectively.

🩸 The client cannot ambulate because of residual epidural numbness, making spontaneous voiding difficult.

🩸 Emptying the bladder allows the uterus to move back to midline and contract more effectively.

🩸 Improved uterine contraction decreases postpartum bleeding.

🩸 Catheterization is an immediate nursing priority.

✅ Administer methylergonovine 0.2 mg IM

🩸 Methylergonovine is a uterotonic that stimulates strong uterine contractions to control postpartum bleeding.

🩸 Since fundal massage failed and oxytocin infusion has already completed, an additional uterotonic is indicated.

🩸 This client’s BP is low, so hypertension is not a contraindication.

🩸 Increased uterine tone helps compress blood vessels and reduce hemorrhage.

🩸 Continuous monitoring of bleeding and uterine firmness is required.

❌ Draw a complete blood count

❌ CBC may be needed later to evaluate blood loss, but it does not stop active hemorrhage.

❌ Immediate stabilization and bleeding control take priority.

❌ Weigh the client’s perineal pad

❌ Blood loss is already quantified (980 mL) and active hemorrhage is evident.

❌ Treatment should not be delayed for additional measurement.

❌ Apply O₂ per nonrebreather mask

❌ Oxygen may become necessary if oxygenation worsens, but the current SpO₂ is 98%.

❌ Correcting the bleeding source is the immediate priority.

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Answer 8

Correct Answers:

Chadwick sign

Rationale :

🤰 Chadwick sign is a probable sign of pregnancy and refers to the bluish-purple discoloration of the cervix, vagina, and vulva caused by increased vascularity and blood flow during pregnancy.

🤰 Probable signs are objective findings observed by the examiner and strongly suggest pregnancy, but they are not absolutely diagnostic.

🤰 Chadwick sign usually appears during the early weeks of pregnancy and is identified during pelvic examination.

🤰 Other probable signs include Goodell sign, Hegar sign, positive pregnancy test, uterine enlargement, and Braxton Hicks contractions.

🤰 Probable signs differ from presumptive signs because they can be observed by another person.

❌ Urinary frequency

❌ Urinary frequency is a presumptive sign of pregnancy because it is subjective and reported by the client.

❌ It may also occur from conditions unrelated to pregnancy.

❌ Amenorrhea

❌ Amenorrhea is considered a presumptive sign, not probable.

❌ Missed menstruation suggests pregnancy but can occur due to stress, illness, or hormonal changes.

❌ Fatigue

❌ Fatigue is also a presumptive sign of pregnancy because it is subjective.

❌ Many conditions other than pregnancy can cause fatigue.

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Answer 9

Correct Answers:

A client who had a miscarriage at 14 weeks of gestation

Rationale :

🤰 Rh(D) immune globulin (RhoGAM) is administered to an Rh-negative client to prevent formation of antibodies against Rh-positive fetal blood cells.

🤰 It is indicated after events that increase the risk of fetomaternal blood mixing, including miscarriage, abortion, ectopic pregnancy, invasive procedures, abdominal trauma, and delivery.

🤰 A miscarriage at 14 weeks gestation places the client at risk for exposure to fetal red blood cells, making Rh(D) immune globulin appropriate.

🤰 Administration helps prevent Rh sensitization, which can affect future pregnancies and lead to hemolytic disease of the fetus and newborn.

🤰 Timing is important—Rh immune globulin is generally administered within the recommended timeframe after exposure.

❌ A client who had surgical placement of a cervical cerclage at 13 weeks of gestation

❌ Cervical cerclage alone is not the classic indication expected in this question unless there is documented fetomaternal hemorrhage.

❌ Pregnancy loss events have higher priority for Rh prophylaxis.

❌ A client who has gestational hypertension

❌ Gestational hypertension alone does not cause fetal blood exposure requiring Rh immune globulin.

❌ Management focuses on maternal and fetal monitoring.

❌ A client who has hyperemesis gravidarum

❌ Hyperemesis affects nutrition and hydration but does not involve fetal blood exposure.

❌ Rh immune globulin is not indicated for nausea and vomiting.

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Answer 10

Correct Answers:

Perform fundal assessment and massage.

Rationale :

🚨 Four saturated perineal pads within 1 hour at 4 hr postpartum strongly suggests postpartum hemorrhage (PPH) and requires immediate intervention.

🚨 The nurse should first assess the uterine fundus and perform fundal massage because the most common cause of early postpartum hemorrhage is uterine atony (failure of the uterus to contract).

🚨 A boggy uterus allows excessive bleeding from uterine vessels that supplied the placenta.

🚨 Fundal massage stimulates uterine contraction, promotes vessel compression, and may rapidly decrease blood loss.

🚨 This action follows the nursing priority of addressing the most likely and reversible cause first before medication administration.

❌ Administer misoprostol

❌ Misoprostol is a uterotonic and may be needed, but assessment of uterine tone comes first.

❌ Medication administration should follow rapid evaluation of the cause of bleeding.

❌ Increase maintenance IV fluid

❌ IV fluids may support circulation, but they do not correct the source of hemorrhage.

❌ Stopping blood loss takes priority.

❌ Perform perineal hygiene

❌ Perineal care is not the immediate priority during active postpartum bleeding.

❌ Hemorrhage assessment and stabilization are urgent.

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QLexNursing

1 :
A nurse is planning care for a newborn who is large for gestational age. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

2 :
A nurse in an antepartum clinic is collecting data from a client who is at 28 weeks of gestation and has preeclampsia. Which of the following findings is the priority?

3 :
A nurse is caring for a client who is pregnant and tests positive for syphilis. Which of the following medications is a contraindication during pregnancy?

4 :
A nurse is assisting in the care of a newborn in the birthing room. Which of following actions should the nurse take?a

5 :
A nurse is reinforcing teaching with a client who has a prepregnancy BMI of 21. How much weight should the nurse recommend the client gain during the course of the pregnancy?

6 :
A nurse is assisting with the care of a client on an intrapartum unit.

Correct Answers

7 :
A nurse is assisting in the care of a client who is 1 hr postpartum.

Answer Options

8 :
A nurse is reviewing signs of pregnancy prior to collecting data from a client at their initial prenatal visit. Which of the following is a probable sign of pregnancy?

9 :
A nurse in a prenatal clinic is planning care for four clients who are Rh-negative. For which of the following clients should the nurse plan to administer Rh.(D) immune globulin?

10 :
A nurse is caring for a client who is 4 hr postpartum. The nurse notes four saturated perineal pads in the past hour. Which of the following actions should the nurse take first?

QLexNursing

1 : A nurse is planning care for a newborn who is large for gestational age. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

2 : A nurse in an antepartum clinic is collecting data from a client who is at 28 weeks of gestation and has preeclampsia. Which of the following findings is the priority?

3 : A nurse is caring for a client who is pregnant and tests positive for syphilis. Which of the following medications is a contraindication during pregnancy?

4 : A nurse is assisting in the care of a newborn in the birthing room. Which of following actions should the nurse take?a

5 : A nurse is reinforcing teaching with a client who has a prepregnancy BMI of 21. How much weight should the nurse recommend the client gain during the course of the pregnancy?

6 : A nurse is assisting with the care of a client on an intrapartum unit.

Correct Answers

7 : A nurse is assisting in the care of a client who is 1 hr postpartum.

Answer Options

8 : A nurse is reviewing signs of pregnancy prior to collecting data from a client at their initial prenatal visit. Which of the following is a probable sign of pregnancy?

9 : A nurse in a prenatal clinic is planning care for four clients who are Rh-negative. For which of the following clients should the nurse plan to administer Rh.(D) immune globulin?

10 : A nurse is caring for a client who is 4 hr postpartum. The nurse notes four saturated perineal pads in the past hour. Which of the following actions should the nurse take first?

1 :
A nurse is planning care for a newborn who is large for gestational age. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

2 :
A nurse in an antepartum clinic is collecting data from a client who is at 28 weeks of gestation and has preeclampsia. Which of the following findings is the priority?

3 :
A nurse is caring for a client who is pregnant and tests positive for syphilis. Which of the following medications is a contraindication during pregnancy?

4 :
A nurse is assisting in the care of a newborn in the birthing room. Which of following actions should the nurse take?a

5 :
A nurse is reinforcing teaching with a client who has a prepregnancy BMI of 21. How much weight should the nurse recommend the client gain during the course of the pregnancy?

6 :
A nurse is assisting with the care of a client on an intrapartum unit.

7 :
A nurse is assisting in the care of a client who is 1 hr postpartum.

8 :
A nurse is reviewing signs of pregnancy prior to collecting data from a client at their initial prenatal visit. Which of the following is a probable sign of pregnancy?

9 :
A nurse in a prenatal clinic is planning care for four clients who are Rh-negative. For which of the following clients should the nurse plan to administer Rh.(D) immune globulin?

10 :
A nurse is caring for a client who is 4 hr postpartum. The nurse notes four saturated perineal pads in the past hour. Which of the following actions should the nurse take first?