Answer is: a. Urine protein of 3+

Explanation:

• Urine protein of 3+ indicates severe proteinuria, which is a sign of preeclampsia and can lead to kidney damage. The nurse should report this finding to the provider as it may require medication or delivery intervention.
• Deep tendon reflexes of 2+ are normal and do not indicate preeclampsia. The nurse should monitor the client for hyperreflexia, which is a sign of increased neuromuscular irritability and can precede seizures.
• Hemoglobin 13 g/dL is within the normal range for a pregnant client and does not indicate preeclampsia. The nurse should monitor the client for anemia, which can cause maternal and fetal complications.
• Blood glucose 110 mg/dL is slightly elevated but not diagnostic of gestational diabetes, which is a different condition from preeclampsia. The nurse should advise the client to follow a balanced diet and exercise regimen and to undergo a glucose tolerance test at 24 to 28 weeks of gestation.

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The correct answer is choice C, Ensure the newborn's eyes are closed beneath the shield. Phototherapy is a treatment used to reduce high bilirubin levels in newborns. It involves exposing the newborn's skin to special lights, which helps to break down the excess bilirubin in the blood. It is important to ensure that the newborn's eyes are closed beneath the shield to prevent damage to the eyes from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr, applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a thin layer of clothing during therapy are not indicated interventions during phototherapy.

Answer and explanation

The correct answer is choice A, Decreased maternal hormones during pregnancy. Breast tissue with a flat areola and no bud is a normal finding in newborns and indicates that the infant did not receive significant amounts of maternal hormones during pregnancy. Preterm gestational age, ambiguous secondary sex characteristics, and congenital anomalies would not typically present with this finding.

The correct answer is choice B, D, C, A. The sequence the nurse should follow when performing suction with a bulb syringe is to compress the bulb syringe, place the bulb syringe in the newborn's mouth, use the bulb syringe to suction the newborn's nose, and then assess the newborn for reflex bradycardia. That sequence is the most effective way to suction a newborn's mouth and nose, as it ensures that the newborn's airway is cleared of mucus before assessing for reflex bradycardia, which can be triggered by suctioning.

The correct statement is C. left lower quadrant. The location where the monitor is placed depends on the position of the fetus. When the fetus is in a left occiput anterior position, the point of maximum impulse of the fetal heart rate is located in the left lower quadrant of the mother's abdomen. This is where the nurse should place the external fetal monitor to obtain an accurate reading of the fetal heart rate.

The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the

abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.

The correct answer is choice A. Breast tissue that has a flat areola with no bud indicates that the newborn received decreased maternal hormones during pregnancy. Maternal hormones stimulate breast tissue growth in the fetus during pregnancy. A flat areola with no bud is a finding that is commonly seen in newborns who received decreased maternal hormones.

The correct answer is choice C. Eating a well-balanced diet and exercising for 30 minutes per day can help to reduce stress and improve mood, which can help to prevent postpartum depression. This provide the body with the essential nutrients it needs to function properly and maintain good health. Exercise can help to reduce stress and improve mood by releasing endorphins, which are hormones that can help to improve mood and reduce stress.

The correct answer is choice A. The nurse should initiate contact precautions for the newborn. The newborn of an HIV-positive mother is at risk of acquiring HIV infection during delivery. To reduce the risk of infection, the newborn should be placed under contact precautions until the results of the newborn's HIV test are available. The nurse should also ensure that the newborn receives appropriate antiretroviral prophylaxis to prevent HIV transmission.

The correct answer is choice D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score." components of the Apgar score:

The score for each component is summed up to a maximum score of 10, with 10 indicating the healthiest newborn. The NRP guidelines emphasize that resuscitation efforts should be initiated immediately after delivery, regardless of the Apgar score, thus choice C is wrong.

The correct answer is choice D. Urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate. Magnesium sulfate is a medication used to treat preeclampsia, a potentially life-threatening condition that can occur during pregnancy. Adverse reactions to magnesium sulfate include hypotension, respiratory depression, and decreased urine output. The nurse should monitor the client's vital signs and urine output closely while the client is receiving magnesium sulfate. Normal urine output in a healthy individual should be between 0.5-1.5 mL/kg/hour, and patients should generally be urinating at least every 6 hours.

Uterine rupture. The sudden, severe lower abdominal pain, drop in blood pressure, and signs of shock such as cool skin and pallor all point to a potential intra-abdominal hemorrhage most likely due to Uterine rupture. Additionally, the prolonged bradycardia on the fetal heart rate tracing indicates that the baby may be experiencing fetal distress due to a compromised blood supply. Amniotic fluid embolism triggers an allergic reaction, causing a sudden onset of respiratory distress, hypotension, and cardiac arrest. Option D, placenta previa, occurs when the placenta implants in the lower uterine segment, partially or completely covering the cervical os. This can lead to painless vaginal bleeding but typically does not present with sudden, severe abdominal pain or signs of shock.

This suggests that the nurse should assess the newborn's latch while breastfeeding. Sore nipples are a common concern among breastfeeding mothers, and the most common cause is an improper latch. The nurse should ensure that the baby is latching on correctly and not causing trauma to the mother's nipples. A proper latch involves the baby taking in a good portion of the areola and not just the nipple. Assessing the newborn's latch can help identify any issues with the baby's mouth or tongue that may be causing difficulty latching on. If the baby is not latching correctly, the nurse can provide education and support to help the mother correct the issue. Offering supplemental formula between feedings (choice A) is not recommended as it can decrease the frequency of breastfeeding and reduce the stimulation for milk production, leading to decreased milk supply. Instructing the client to wait 4 hours between daytime feedings (choice C) is not recommended as it can decrease milk production and lead to inadequate nutrition for the newborn.

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May 13. Nägele's Rule is used to calculate the estimated date of delivery (EDD) based on the first day of the last menstrual period (LMP). To use this rule, the nurse subtracts 3 months from the first day of the LMP and adds 7 days and 1 year.

For this client, the first day of her LMP was August 10. Subtracting 3 months gives us May 10. Adding 7 days gives us May 17. Adding 1 year gives us May 17, 2022. Therefore, the estimated date of delivery is May 17, 2022.

It is important to note that Nägele's Rule is an estimation, and not all pregnancies follow the typical 280-day gestational period. Other factors, such as irregular menstrual cycles, can affect the accuracy of the estimated date of delivery. The nurse should monitor the client's pregnancy and adjust the estimated date of delivery as needed based on ultrasound results and other clinical findings.

Three uterine contractions within a 20-min period require intervention by the nurse during a nonstress test at 35 weeks of gestation. The nonstress test is used to assess fetal well-being by monitoring the fetal heart rate (FHR) response to fetal movement. The test is considered reactive if there are two or more accelerations of the FHR within a 20-min period, each lasting at least 15 seconds and peaking at least 15 beats above the baseline. In this scenario, the finding that requires intervention by the nurse is three uterine contractions within a 20-min period. This is because frequent or prolonged contractions can indicate preterm labor, which requires immediate intervention

to prevent premature delivery. The nurse should assess the client for signs and symptoms of preterm labor, such as pelvic pressure, low back pain, vaginal bleeding or discharge, and abdominal cramping. The nurse should also notify the provider and prepare the client for further evaluation and possible interventions, such as tocolytic therapy to stop the contractions.

The mother is Rh negative and the father is Rh positive. Hemolytic disease of the newborn (HDN) is caused by an incompatibility between the blood types of the mother and fetus. Specifically, it occurs when a Rh-negative mother carries a fetus who is Rh-positive, and the mother's immune system produces antibodies against the Rh antigen on the fetal red blood cells. These antibodies can cross the placenta and destroy the fetal red blood cells, leading to anemia and other complications in the newborn. If a mother has Rhnegative blood, it means that she lacks the Rh antigen on her red blood cells. If the father has Rh-positive blood, there is a chance that the fetus will inherit the Rh antigen from the father. If the fetal Rh-positive blood enters the mother's bloodstream during pregnancy or delivery, the mother's immune system can produce antibodies against the Rh antigen, causing HDN in subsequent pregnancies with Rh-positive fetuses.

The nurse should report a respiratory rate of 10/min to the provider following the administration of butorphanol IV bolus. Butorphanol is an opioid agonist-antagonist analgesic that can cause respiratory depression as a side effect. Therefore, it is important to monitor the client's respiratory rate and depth closely after administration of the medication. A respiratory rate of 10/min is significantly lower than the normal range of 1220/min, and may indicate respiratory depression. The nurse should also monitor the client's blood pressure, urinary output, and fetal heart rate for any changes, but these findings are not necessarily indicative of a complication following the administration of butorphanol.

The correct answer is choice C, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. This client's low sodium level indicates hyponatremia, which can lead to seizures and brain damage if not corrected promptly. The nurse should assess the client's neurologic status, including level of consciousness, reflexes, and motor function, and notify the provider immediately. The other clients also require close monitoring and intervention, but their conditions are not as urgent as the client with hyponatremia. Clients with preeclampsia require monitoring of blood pressure and kidney function, clients with placenta previa require monitoring of bleeding and hematocrit levels, and clients with diabetes mellitus require monitoring of blood glucose levels and HbA1c.

Lentils. Lentils have the highest fiber content per cup compared to the other options. One cup of cooked lentils provides approximately 15.6 grams of fiber. Oatmeal provides approximately 4 grams of fiber per cup, asparagus provides approximately 3.6 grams of fiber per cup, and cabbage provides approximately 2.6 grams of fiber per cup. Increasing dietary fiber is an effective way to manage constipation during pregnancy, as it can promote bowel regularity and prevent complications such as hemorrhoids. The nurse can provide additional education on other high-fiber food options, the importance of drinking adequate fluids, and the need to increase physical activity to help manage constipation.

The correct answer is choice C. Ultrasonography is a diagnostic tool used during pregnancy to visualize the fetus and the maternal reproductive organs. In the first trimester of pregnancy, it is primarily used to determine gestational age, confirm the presence of an intrauterine pregnancy, and assess for fetal viability. It can also be used to identify multiple gestations, evaluate for ectopic pregnancy, and detect certain fetal anomalies. Ultrasound is not typically used to observe for placental maturity or to perform a biophysical profile in the first trimester. Intrauterine growth restriction is typically assessed later in pregnancy using serial ultrasound measurements.

The client's cervical dilation and effacement indicate that she is in active labor and progressing rapidly. Because the client is already 8 cm dilated and has been in labor for only 1 hour, the nurse should recognize that the client is at risk for a rapid delivery, which can increase the risk of postpartum hemorrhage. The other options listed are not associated with cervical dilation and effacement during active labor.

Respiratory rate 55/min. This finding is abnormal and requires immediate reporting to the provider. The normal range for a newborn respiratory rate is 30-60 breaths per minute, and a rate above this range may indicate respiratory distress or another underlying issue that requires further assessment and intervention. The heart rate, temperature, and blood pressure are within the normal range for a full-term newborn and do not require reporting to the provider unless they deviate significantly from the expected range.

A sense of excitement and warm, flushed skin should prompt the nurse to reassess the client, as it may indicate hyperventilation, which can lead to respiratory alkalosis and decreased uterine blood flow. The nurse should encourage the client to breathe slowly and deeply during contractions to help prevent hyperventilation. Choices A, B, and C are normal findings during labor and do not require immediate reassessment. Progressive sacral discomfort during contractions can indicate the descent of the fetal head. Intense contractions lasting 45 to 60 seconds can indicate active labor. The urge to have a bowel movement during contractions can indicate fetal descent and pressure on the rectum.

The nurse should explain to the client that amniocentesis is a diagnostic test that is performed between 15 and 20 weeks of gestation to determine if the fetus has genetic or congenital disorders. While the procedure can also determine the sex of the fetus, this is not typically the primary reason for the test. The nurse should clarify any misconceptions the client has about the procedure and provide education on its purpose, risks, and benefits. The nurse should also assess the client's understanding of the information provided and address any questions or concerns the client may have.

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An early deceleration is a type of fetal heart rate deceleration that is typically benign and caused by the pressure of the baby's head on the cervix during contractions. However, it can also be caused by uterine hyperstimulation, which is a potential complication of oxytocin administration. Discontinuing the oxytocin can help to alleviate uterine hyperstimulation and prevent further decelerations. Administering oxygen, assisting the client to lay on her right side, and continuing to monitor the client may also be appropriate interventions, but discontinuing the oxytocin is the priority action in this situation.