Deck 33: Reproduction

Question 1

The nurse is providing care to a client whose last menstrual period was 6 weeks ago.The client believes she is pregnant.Which diagnostic test does the nurse anticipate in order to confirm the pregnancy?

A) Serum or urine human chorionic gonadotropin (hCG)
B) Fetal heartbeat by Doppler
C) Fetal heartbeat by fetoscope
D) Fetal movement

Answer 1

Serum or urine human chorionic gonadotropin (hCG)

Question 2

A client at 12 weeks' gestation with her first child tells the nurse that she is concerned that her husband does not want the baby because he has a renewed interest in playing tennis and visiting with college friends after work.When responding to the client,which should the nurse take into consideration?

A) This is a normal reaction by fathers that is seen in the second trimester of pregnancy.
B) This is a normal reaction by fathers that is seen in the third trimester of pregnancy.
C) This is a normal reaction by fathers that is seen in the first trimester of pregnancy.
D) This is an atypical reaction of the father to pregnancy that should be further examined.

Answer 2

This is a normal reaction by fathers that is seen in the first trimester of pregnancy.

Question 3

While reviewing exercises to do when pregnant,a client of European descent tells the nurse that she was taught never to reach over the head because this will harm the baby.Based on this data,which action by the nurse is appropriate?

A) Provide dietary instruction to ensure the client does not gain excessive weight.
B) Suggest limiting exercise to household chores.
C) Provide alternative activities to do instead of exercise.
D) Assure that reaching over the head will not harm the baby.

Answer 3

Assure that reaching over the head will not harm the baby.

Question 4

A client who recently learned of being pregnant tells the nurse that she stopped eating meat years ago and started eating fish daily because it is healthier.Which teaching points are appropriate for this client based on her current diet? Select all that apply.

A) Avoid shrimp, salmon, and catfish because these have higher mercury levels.
B) Eat up to 12 ounces a week of a variety of fish and shellfish.
C) Avoid albacore tuna because it has more mercury than other canned tuna.
D) Eat plenty of fish such as swordfish and shark while pregnant.
E) Follow a complete vegetarian diet while pregnant as an alternative to eating fish.

Question 5

An adolescent client at 34 weeks' gestation states to the nurse,"I am stressed out about becoming a mother.I hope that I can get back to my normal day to day activities after the baby is born." In order to elicit the appropriate information from the client,which question by the nurse is the most appropriate?

A) "Are your friends excited about the baby coming and planning a shower for you?"
B) "Have you done anything to prepare for the baby coming home after delivery?"
C) "Do you miss going out with your friends on the weekends?"
D) "Have you been able to get enough rest while keeping up with your studies?"

Question 6

The nurse is instructing a client who is at 10 weeks' gestation on smoking cessation and avoiding substance abuse.Which is the rationale for why these should be avoided during pregnancy?

A) Interferes with hormone excretion of the fetus.
B) Facilitates the transfer of viruses and other diseases into the developing fetus.
C) Passes into the developing fetus through the placenta very easily.
D) Stops the synthesis of protein in the developing fetus.

Question 7

A client at 16 weeks' gestation is diagnosed with tuberculosis (TB).Which statements by the nurse are appropriate when instructing the client regarding the needs for both the client and fetus? Select all that apply.

A) "You have been prescribed Isoniazid; therefore, you must also take pyridoxine (vitamin B₆)."
B) "Your contact with the baby will be limited for several months after delivery."
C) "You will not be able to breastfeed your baby because of this diagnosis."
D) "You are free to have contact with anyone as TB is not contagious when diagnosed during pregnancy."
E) "Take Rifampin as prescribed."

Question 8

The nurse is providing care to a client who is experiencing nausea and vomiting during the first trimester of pregnancy.Which actions by the nurse are appropriate based on this data? Select all that apply.

A) Notify the healthcare provider that the client is experiencing hyperemesis gravidarum.
B) Educate the client to notify the healthcare provider if she vomits once per day
C) Suggest the client use acupressure to pressure points on the wrist
D) Teach the client that ginger may relieve her symptoms
E) Caution the client against using over-the-counter medications such as over-the-counter antihistamines

Question 9

A client is surprised to learn of being pregnant because the home pregnancy test was negative when it was used a month ago.Which response by the nurse is appropriate?

A) "Home pregnancy tests are unreliable and should not be used without an ultrasound afterward to confirm pregnancy."
B) "Home pregnancy tests can provide a false negative and should be repeated in a week if your period has not yet started."
C) "Home pregnancy tests are unreliable and should not be used without a blood sample being drawn afterward."
D) "Home pregnancy tests lose their effectiveness after 6 months, and your kit was probably old."

Question 10

A client who is at 12 weeks' gestation is experiencing nausea,breast tenderness,and fatigue.She tells the nurse her husband is upset with her constant complaints.Which is the priority nursing diagnosis based on this data?

A) Ineffective Breastfeeding
B) Dysfunctional Family Processes
C) Nausea
D) Fatigue

Question 11

The nurse is teaching a pregnant client,with a history of back pain,childbirth exercises.Which is most appropriate for this client?

A) Perform the pelvic rock exercise only in the standing position.
B) Exercise in the supine position throughout the pregnancy.
C) Perform the pelvic rock exercise while in the hands and knees position.
D) Soak in a hot tub for approximately 30 minutes after exercise.

Question 12

A client who says she is "about 6 weeks pregnant" hears the baby's heartbeat for the first time through a Doppler.Based on this data,which conclusion by the nurse is the most appropriate?

A) The mother is at 8 to 12 weeks' gestation.
B) The mother is at 16 weeks' gestation.
C) The mother is at 4 to 8 weeks' gestation.
D) The mother is at 20 weeks' gestation.

Question 13

A nurse working in an OB/GYN outpatient clinic finds that on a routine anemia screen a pregnant client in her second trimester has a hemoglobin of 10 g/dL and a serum ferritin level of 11 mg/L.The client confirms fatigue,but otherwise feels fine.Which actions by the nurse are appropriate when providing care to this client? Select all that apply.

A) Complete a further history and exam to carefully assess for any potential cause of bleeding.
B) Review a list of iron-rich foods and explore with the client how she can increase dietary iron.
C) Have the client continue her usual daily prenatal vitamin dose.
D) Stress the importance of complying with an increase in iron supplementation to 100 mg per day.
E) Ask the client to return in 2 months for a repeat check of her serum iron levels. F) Order a screening for sickle cell anemia.

Question 14

The nurse is providing care to a pregnant client who will undergo chorionic villi sampling.The client is currently 8 weeks pregnant.When teaching the client about this genetic testing,which layer of the embryonic membrane is tested during this procedure?

A) Chorion
B) Amnion
C) Ectoderm
D) Endometrium

Question 15

The nurse is providing care to a pregnant client who is experiencing ptyalism.Which will the nurse include in the plan of care for this client?

A) Use a cool-mist vaporizer
B) Suck on hard candy
C) Avoid use of nasal sprays and decongestants
D) Use low-sodium antacids

Question 16

A client in the first trimester of pregnancy complains of a vaginal discharge and is concerned that the baby is infected.Which instructions by the nurse are appropriate? Select all that apply.

A) Avoid douching.
B) Keep the vaginal area clean and wear cotton underwear.
C) See the healthcare provider to assess for a vaginal infection.
D) Limit bathing to 2 times a week.
E) Limit dairy products and use lactose-free products whenever possible.

Question 17

The spouse of a pregnant client tells the nurse that he is not sure he is ready to be a father and wishes his wife had not gotten pregnant.Which response by the nurse is appropriate?

A) "Do you think you wife got pregnant on purpose, without your consent?"
B) "Have you considered giving the baby up for adoption?"
C) "Tell me more about why you feel this way."
D) "Every husband has these feelings, and many times they never go away."

Question 18

A pregnant adolescent client asks for information about the pregnancy and the baby because she cannot afford to prenatal care.Which action by the nurse is the most appropriate?

A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery.
B) Instruct the client on aspects of pregnancy, fetal development, and labor and delivery.
C) Ask the client if her parents are aware that she is pregnant and if she is covered by their medical insurance.
D) Tell the client that the father of the baby is responsible to pay for medical care for her during the pregnancy and after delivery.

Question 19

A client,who underwent in-vitro fertilization,presents at the OB-GYN clinic for pregnancy testing.When teaching the client about the test,which statement is appropriate?

A) "We will draw blood to determine if you are pregnant. Early pregnancy factor (EPF) is detected in your blood 24 to 48 hours after fertilization."
B) "Please provide a urine sample. Early pregnancy factor (EPF) is detected in your urine 24 to 48 hours after fertilization."
C) "We will draw blood to determine if you are pregnant. Human chorionic gonadotropin (hCG) is detected in your blood 24 to 48 hours after fertilization."
D) " Please provide a urine sample. Human chorionic gonadotropin (hCG) is detected in your blood 24 to 48 hours after fertilization."

Question 20

A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time.To assist this client,the nurse should instruct her to do which of the following?

A) Drink a glass of water every time nausea occurs.
B) Take a multivitamin without iron each day.
C) Take over-the-counter Benadryl for the nausea.
D) Take a multivitamin with iron each day.

Question 21

The laboring client's fetal heart rate baseline is 120 beats per minute (bpm).Accelerations are present to 135 bpm.During contractions,the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction.Which nursing action is appropriate?

A) Documenting the fetal heart rate
B) Preparing for imminent delivery
C) Applying oxygen via mask at 10 liters
D) Assisting the client into the Fowler's position

Question 22

A pregnant client presents to the emergency department reporting that she has started labor and is certain the baby is coming "any minute now" and asks to be taken up to the delivery suite.After assessing and monitoring the client,the nurse determines that the client is in "false" labor and is preparing her to for discharge.Which observations support the nurse's conclusion? Select all that apply.

A) The contractions do not have a regular pattern.
B) Her cervix has dilated 2 cm over the 2 hours of observation.
C) The frequency and intensity of the contractions have stayed about the same.
D) Walking seems to increase the strength of the contractions.
E) The contractions are mostly in her abdomen.

Question 23

The nurse is providing care to a postpartum client who gave birth 4 hours ago.The client has a mediolateral episiotomy,large hemorrhoids,and states pain is a 7 on a scale of 1-10.She has a history of anaphylactic reaction to Tylenol.Based on this data,which nursing action is appropriate?

A) Encourage use of benzocaine topical anesthetic spray (Dermoplast).
B) Provide 2 oxycodone with acetaminophen (Percocet) by mouth.
C) Offer the client 800 mg ibuprofen (Advil) orally with food.
D) Run very warm water into the tub and assist her into the bath.

Question 24

A client in the fourth stage of labor is crying out in pain.Which nursing diagnosis is the priority at this time?

A) Health-Seeking Behaviors
B) Fear
C) Anxiety
D) Acute Pain

Question 25

A postpartum client is experiencing pain from an episiotomy.Which actions will the nurse suggest to the client to decrease discomfort? Select all that apply.

A) Washing the area with soap and water every day
B) Tightening the buttocks before sitting
C) Changing peripads daily
D) Performing leg scissor kicks several times a day
E) Increasing the intake of meat, cheese, fish, eggs, and nuts

Question 26

A client who gave birth to her first child 12 hours ago has the following assessment findings: nausea for 2 hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on scale of 1-10.The client's partner is present and supportive.Breastfeeding has been successful three times.Based on this data,which is the priority nursing diagnosis?

A) Acute Pain related to perineal trauma
B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea
C) Deficient Knowledge related to birth of first child
D) Readiness for Enhanced Family Coping related to partner involvement

Question 27

Upon delivery of the newborn,which nursing intervention promotes parental attachment?

A) Placing the newborn under the radiant warmer
B) Placing the newborn on the bed next to the mother
C) Placing the newborn on the maternal abdomen
D) Taking the newborn to the nursery for the initial assessment

Question 28

The nurse is reviewing the immunization record for a client who just learned she is pregnant.Which vaccine is not safe to give during pregnancy?

A) Pertussis
B) Annual influenza
C) Rubella
D) Tetanus

Question 29

The nurse is providing postpartum care to a client from a different culture.What nursing actions are appropriate to include in the client's plan of care? Select all that apply.

A) Assess for any assistance required during breastfeeding.
B) Ask if there are any specific customs the client wants to follow.
C) Assess for any specific foods or fluids to hasten recovery.
D) Limit client visitors to the immediate family.
E) Restrict interactions with the client.

Question 30

The nurse is planning care for a client who had a cesarean birth 4 hours ago.Which actions should be included in this client's plan of care? Select all that apply.

A) Encourage the use of breathing, relaxation, and distraction.
B) Encourage deep breathing and coughing every 2 to 4 hours.
C) Encourage to ambulate to the bathroom to void.
D) Discourage leg exercises.
E) Withhold all analgesics.

Question 31

The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor.Which client statement indicates appropriate understanding of the information presented?

A) "During labor, the nurse will verify that my contractions are strong but not too close together."
B) "During labor, the nurse will look at the color and amount of bloody show that I have."
C) "During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor."
D) "During labor, the nurse will check my cervix by doing a pelvic exam every two hours."

Question 32

The nurse is providing care to the client during the second stage of labor.Which nursing action is appropriate?

A) Assessing maternal temperature every 2-4 hours after amniotic membranes have ruptured
B) Encouraging the client to void because a full bladder can interfere with fetal descent
C) Assessing fetal heart rate every 15 minutes in low risk clients
D) Administering antibiotics for a positive group beta strep

Question 33

During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago,the nurse assesses the following: fundus firm and at the umbilicus,and moderate lochia rubra with a steady trickle of blood noted from the vagina.Which assessment finding requires immediate follow-up?

A) Moderate lochia rubra
B) Steady trickle of blood
C) Fundus at the umbilical level
D) Firm fundus

Question 34

During an assessment,the nurse notes the postpartum client is experiencing intense shaking and chills.Based on this data which conclusion by the nurse is appropriate? Select all that apply.

A) This is evidence of incomplete expulsion of the placenta.
B) The client has a full bladder.
C) This may be a reaction to maternal adrenal production during labor and birth.
D) This may be a reaction to epidural anesthesia.
E) The client has a fever from a postpartum infection.

Question 35

The nurse is providing care to a client,with a history of rheumatoid arthritis (RA),who is 5 months pregnant.Which nursing actions are appropriate when providing care to this client? Select all that apply.

A) Telling the client there is an increased risk for preterm delivery because of salicylate therapy
B) Monitoring the client for anemia due to salicylate therapy
C) Suggesting the client begin supplemental pyridoxine
D) Educating the client that medication therapy may be discontinued due to remission
E) Teaching the client that RA may be contracted by the fetus during pregnancy

Question 36

The nulliparous states,"I have been in labor for 4 hours and I am still only 2 cm dilated.Why is this happening? I feel like I should be ready to push by now." Which is the best response by the nurse?

A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now."
B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix."
C) "What did you expect? You've only had contractions for a few hours. Labor takes time."
D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."

Question 37

The nurse is caring for a pregnant client who has asthma.The client has a cold and has an exacerbation of asthma symptoms,including mild wheezing.To help avoid hypoxia-related complications in the fetus,which medication prescription does the nurse anticipate?

A) IV corticosteroid (e.g., prednisone)
B) Oral pseudoephedrine (e.g., Sudafed)
C) Inhaled beta2-agonist (e.g., albuterol)
D) Oral acetylsalicylic acid (e.g., aspirin)

Question 38

The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes.The fetus is in the vertex position.The nurse notes that the amniotic fluid is meconium stained.Based on this data,which is the priority action by the nurse?

A) Notifying the healthcare provider that birth is imminent
B) Changing the client's position in bed
C) Beginning continuous fetal heart rate monitoring
D) Administering oxygen at 2 liters per minute

Question 39

The nurse is instructing a postpartum client on when she can resume her normal exercise regimen of running for exercise most days of the week.Which statement indicates that teaching was effective?

A) "I can start my exercise regimen in 2 weeks."
B) "I will not be able to exercise because it is not recommended for breastfeeding women."
C) "I can exercise if I get 8 hours of sleep per day."
D) "I should check my energy level at home and increase exercise slowly."

Question 40

During the fourth stage of labor,a client's blood pressure is 110/60 mmHg,pulse 90,and the fundus is firm,midline and halfway between the symphysis pubis and the umbilicus.Based on this data,which is the primary action by the nurse?

A) Massage the fundus.
B) Turn the client onto the left side.
C) Place the bed in the Trendelenburg position.
D) Continue to monitor.

Question 41

The nurse is providing care to a newborn during the first 24 hours of life.Which is an abnormal finding?

A) Respiratory rate of 58 breaths per minute
B) Heart rate of 140 beats per minute
C) Presence of meconium stool
D) Yellowing of the skin

Question 42

When planning the care for a preterm infant with ineffective thermoregulation,the nurse should include which intervention?

A) Keep the baby's head uncovered.
B) Rinse hands with cold water before providing care to the infant.
C) Place incubator near a window or source of fresh air.
D) Allow skin-to-skin contact with the mother to maintain warmth.

Question 43

When administering an intramuscular dose of vitamin K (AquaMEPHYTON)to a newborn,which actions by the nurse are appropriate? Select all that apply.

A) Using a 23-gauge 1/2-inch needle
B) Cleaning the skin with an alcohol swab
C) Preparing 5 mg of the medication for injection
D) Using the middle third of the vastus lateralis muscle
E) Washing the skin with soap and water

Question 44

When palpating the fundus of a woman on her first day postpartum,the nurse finds that the woman's uterus is higher than expected and is deviated to the right.She is not having excessive uterine bleeding.Which is the priority nursing action for this client?

A) Notify the client's midwife of this condition.
B) Ask another nurse to assess the client to verify the findings.
C) Ask the client to void and then reassess fundal height.
D) Perform a straight catheterization on the client and then reassess fundal height.

Question 45

The nurse is monitoring the intake and output for a preterm infant.Which action by the nurse indicates correct assessment technique when monitoring urine output?

A) Document "unable to obtain" on the graphic sheet.
B) Apply an external condom catheter.
C) Insert an indwelling urinary catheter.
D) Weigh diapers using the estimate that 1 ml = 1 gram of weight.

Question 46

A nurse is caring for a premature infant with a central line.The infant suddenly develops apnea,bradycardia,and metabolic acidosis.Which is the most likely condition causing this change in health status?

A) Hyperbilirubinemia
B) Bacterial sepsis
C) Hypoglycemia
D) Intracranial hemorrhage

Question 47

The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate < 100 beats per minute (1 point); slow,irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point).Based on this data,which nursing action is appropriate?

A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery
B) Swaddling the newborn to decrease the risk of increased energy expenditure
C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing
D) Repeating the assessment every 5 minutes for up to 20 minutes

Question 48

The nurse is instructing the parents who delivered their first child at 34 weeks' gestation.Which statements made by the parents indicate that additional teaching is needed? Select all that apply.

A) "Tube feedings will be required because his stomach is small."
B) "Breathing might be harder for our baby because he is early."
C) "Our baby will be in an incubator to keep him warm."
D) "The growth of our baby will be slower than if he were term."
E) "Because he came early, he will not produce urine for two days."

Question 49

After giving birth to a preterm infant who is being cared for in the neonatal intensive care unit (NICU),an adolescent client says,"My baby doesn't seem real because she's in the hospital and I'm at home." What can the nurse do to promote parent-infant attachment?

A) Limit visits to the intensive care unit so as not to disrupt care of the baby needs.
B) Explain that once the baby is discharged to home, she will have evidence that the baby is real.
C) Have the mother visit when the baby is asleep or resting.
D) Provide a picture of the infant including a footprint and current weight and length.

Question 50

A nurse is caring for the 1-hour-old newborn of a diabetic mother.Which actions will the nurse include in the newborns plan of care? Select all that apply.

A) Assess blood glucose hourly and then every 4 hours.
B) Evaluate blood glucose levels at birth and at 6-hour intervals.
C) Assess for hyperthyroidism.
D) Assess the newborn's temperature hourly.
E) Use formula for all feedings, avoiding 5% dextrose.

Question 51

The nurse is preparing to provide an enteral feeding to a preterm infant.Which is the priority nursing action prior to administering the feeding?

A) Weigh the current diaper.
B) Measure abdominal girth.
C) Weigh the baby.
D) Measure pulse oximetry.

Question 52

The nurse is providing care to a client who gave birth to a newborn by cesarean section.When providing care to this client,which nursing actions are appropriate? Select all that apply.

A) Encouraging coughing and deep breathing every 2 hours until the client is able to ambulate
B) Monitoring the episiotomy site every shift
C) Encouraging the client to lay on the right side to promote passing gas
D) Assessing bowel sounds every 8 hours
E) Assessing the client hourly while receiving a continuous epidural infusion

Question 53

The nurse is providing discharge instructions for a first time mother and her baby.Which statement is appropriate for the nurse to include in the teaching session?

A) "Your baby's stools will change to a dark green color when your milk comes in."
B) "Call your pediatrician if the baby's temperature is 98°F."
C) "Your infant should have 6 wet diapers each day."
D) "You can wipe away any green eye drainage that might form."

Question 54

The nurse is instructing a new mother on how to care for the newborn's circumcision site.Which statements indicate that the nurse's education session was effective? Select all that apply.

A) "I should not use petroleum jelly on the penis."
B) "Every time I change the diaper I am to wash the area with warm water."
C) "I should report any pus drainage or change in diaper wetness to the physician."
D) "Swelling is expected."
E) "I am to use soap and water to remove yellow tissue on the penis."

Question 55

The nurse receives shift change report on infants born within the last 4 hours.Which newborn should the nurse assess first?

A) Newborn born at 37 weeks gestation. Respiratory rate of 45 breaths per minute.
B) Term newborn, 2 hours old, who has not passed a meconium stool.
C) Term newborn born yesterday. Heart rate is 150 beats per minute.
D) Term newborn born 1 hour ago who is exhibiting grunting respirations.

Question 56

The nurse is providing care to a newborn born after 37 weeks gestation.The newborns weight is 1,750 g (3 pounds,10 ounces).The head circumference and length are at the 25th percentile.What statement would the nurse use to describe these assessment findings?

A) Preterm appropriate for gestational age, asymmetrical intrauterine growth restriction
B) Preterm appropriate for gestational age, symmetrical intrauterine growth restriction
C) Preterm small for gestational age, asymmetrical intrauterine growth restriction
D) Term small for gestational age, symmetrical intrauterine growth restriction

Question 57

The nurse is proving care to a 1-hour old newborn who was born at 39 weeks' gestation.Which assessment data is cause for concern? Select all that apply.

A) Respiratory rate of 72 breaths per minute
B) Negative Babinski reflex
C) Mean blood pressure of 52 mmHg
D) Acrocyanosis
E) Presence of meconium stool

Question 58

A client of Hispanic descent delivers a newborn son and plans to breastfeed.When the nurse attempt to help the newborn latch on for breastfeeding the client states,"I would like to bottle feed my baby for the first few days." Which reason does the nurse anticipate regarding why the client wants to delay breastfeeding?

A) Colostrum is bad for the baby.
B) Breast milk causes skin rashes.
C) It will cause "evil eye."
D) Thin milk causes diarrhea.

Question 59

The mother of a preterm infant tells the nurse that she was not looking forward to having a baby and now that the baby is sick,she feels worse.Which nursing diagnosis is appropriate based on this data?

A) Parental Role Conflict
B) Impaired Parenting
C) Dysfunctional Family Processes
D) Ineffective Family Coping

Question 60

The nurse educator is teaching a group of nursing students about factors that increase the risk for premature birth.Which statements are appropriate for the educator to include? Select all that apply.

A) "Married women are at an increased risk for giving birth to a premature infant."
B) "Single women are at an increased risk for giving birth to a premature infant."
C) "Lesbians have an increased risk for premature labor."
D) "Adolescent clients are at an increased risk for giving birth to a premature infant."
E) "Pregnancy after the age of 33 years increases the risk for premature labor."

Question 61

The nurse is assessing a premature newborn who is being care for in the newborn intensive care unit (NICU).Which assessment finding indicates the newborn is experiencing respiratory distress?

A) Acrocyanosis
B) Respiratory rate of 58 breaths per minute
C) Substernal and intercoastal retractions
D) Abdominal breathing