Chapter 12: Intra & Postpartum Periods (Test)

A 29-year-old multiparous client who has had an uneventful, healthy pregnancy is admitted to the hospital. The physician informs the client that the active phase of the first stage of labor is in process. The records also show that the full-term baby is in the left occipitoposterior (LOP) position. When the fetus is in the LOP position, which nursing intervention is most appropriate? 1. Assisting the client to the knee-chest position to relieve back pain 2. Placing the client in Trendelenburg position to prevent cord prolapse 3. Assisting with preparation of equipment for a precipitous delivery 4. Having the client void frequently to minimize displacement of the uterus

1

To correctly assess the duration of a contraction, the nurse counts the time between which intervals? 1. The beginning of one contraction and the end of the same contraction 2. The end of one contraction and the beginning of the next contraction 3. The beginning of one contraction and the end of the next contraction 4. The beginning of one contraction and the beginning of the next contraction

1

When reviewing the client's medical records, the nurse notes that the client's rubella titer is low (less than 1:10) and is scheduled to receive the rubella vaccine before discharge. Before giving the vaccine, the nurse should determine if the client is allergic to which medication? 1. Neomycin sulfate (Mycifradin) 2. Erythromycin estolate (Ilosone) 3. Tetracycline (Panmycin) 4. Doxycycline (Vibramycin)

1

The nurse should carefully monitor the client for which adverse reactions to terbutaline sulfate (Brethine)? Select all that apply. 1. Anxiety 2. Tremors 3. Nervousness 4. Hypoglycemia 5. Oliguria 6. Rash

123

The parents of a preterm newborn ask the nurse why their baby is being monitored for signs of infection. The nurse correctly explains that preterm newborns are at risk for developing infections primarily for which reason? 1. Their fragile skin may tear. 2. They lack maternal antibody protection. 3. They are exposed to numerous bacterial organisms. 4. They need to undergo many invasive procedures .

2

Which assessment finding by the nurse best indicates the presence of a perineal hematoma? 1. The client complains of a feeling of fullness in the vagina. 2. Lochia rubra is heavy and foul-smelling. 3. There is separation and purulent drainage from the episiotomy. 4. The client complains of severe pain in the perineal area.

4

Which finding by the nurse is most suggestive of cystitis in the postpartum client? 1. Boggy uterus displaced to the right of the abdominal midline 2. Complaint of increased thirst and voiding large amounts of urine 3. Urine retention and swelling of the lower extremities 4. Complaint of painful urination and presence of blood in the urine

4

Which instruction should the nurse plan to include in the discharge teaching plan for the client who is at risk for developing mastitis? 1. Wear a breast binder between breast-feedings. 2. Apply petroleum jelly to the nipples before breast-feeding. 3. Clean the nipples with soap and water after breast-feeding. 4. Wash both hands before handling the breasts .

4

Which actions should the nurse perform immediately after the membranes are ruptured? Select all that apply. 1. Check the client's pulse. 2. Insert an indwelling catheter. 3. Perform a vaginal examination. 4. Check the fetal heart rate. 5. Inspect the fluid for meconium 6. Prepare the room for imminent delivery

45

Which modification to the client's care plan is required after the client has undergone the epidural? 1. Oxygen is administered. 2. The nurse instructs the client when to push. 3. Oxytocin (Pitocin) is administered to augment labor. 4. The client is catheterized

2

Which nursing action best meets the client's needs during the transition phase? 1. Encouraging the client to ambulate 2. Praising the client frequently 3. Instructing the client to push with each contraction 4. Massaging the client's back between contractions

2

Which nursing intervention is most appropriate for relieving discomfort associated with episiotomy repair? 1. Sitz bath 2. Ice pack 3. Heat lamp 4. Topical cortisone

2

Which method is most accurate when assessing the client's contractions? 1. Place the hand over the fundus of the uterus, which is located just above the umbilicus. 2. Place the hand over the inferior portion of the uterus, which is located just above the umbilicus. 3. Place the hand over the fundus of the uterus, which is located midway between the umbilicus and the symphysis pubis. 4. Place the hand over the inferior portion of the uterus, which is located midway between the umbilicus and the symphysis pubis.

1

Which sequence should the nurse follow when cleaning the client' s perineum in preparation for delivery of the baby? 1. Pubic bone to lower abdomen, both inner thighs, right and left labia, vagina to anus 2. Vagina to anus, right and left labia, both inner thighs, pubic bone to lower abdomen 3. Both inner thighs, right and left labia, vagina to anus, pubic bone to lower abdomen 4. Left and right labia, vagina to anus, both inner thighs, pubic bone to-lower abdomen

1

A 30-year-old primigravid client is admitted to the labor, delivery, recovery, and postpartum (LDRP) unit of a local hospital. The physician plans to perform a vaginal examination to determine the status of labor. How can the nurse best prepare to assist with the vaginal examination? 1. By having sterile gloves available for the examiner 2. By placing the client in the left side-lying position 3. By instructing the client to halt breathing during the examination 4. By giving the client an enema before the examination is performed

1

A 25-year-old primigravid client in the last trimester of pregnancy calls the physician 's office and tells the nurse, "I think I'm in labor." Which findings would warrant instructing the client to notify the physician and report to the hospital's labor and delivery unit immediately? Select all that apply. 1. The client is having contractions every 5 minutes. 2. The client feels a burst of energy. 3. The client experiences a sudden gush of fluid from her vagina. 4. The client experiences urinary frequency. 5. The client notices blood-tinged mucous from her vagina. 6. The client reports that she has felt the baby "drop."

13

During the latent phase of labor, which instructions given by the nurse to the client are most appropriate? Select all that apply. 1. "As long as your membranes are intact, you may walk around the unit." 2. "Keep drinking clear fluids." 3. "Pant when you experience a contraction." 4. "Avoid bathing until after the delivery." 5. "Put on your call light when you feel a contraction coming on." 6. "You may have pain medication when your contractions are 2 minutes apart."

12

During the latent phase, which findings can the nurse expect when assessing the client? Select all that apply. 1. Contractions occurring every 10 to 15 minutes 2. Fetal heart rate of 120 to 160 beats/minute 3. Bulging perineum 4. Early decelerations 5. The client is irritable 6. The client states, "I feel my bowels may move"

12

Just after the delivery of the placenta, the client complains of uncontrollable shaking and of being cold. Which actions by the nurse are most appropriate at this time? Select all that apply. 1. Explain that the shaking is normal. 2. Place a warmed blanket over the client. 3. Suggest the client try to ignore the shaking. 4. Notify the physician or nurse-midwife. 5. Take the client's temperature. 6. Provide a warm beverage.

12

The client is readmitted to the hospital on the fifth postpartum day with a tentative diagnosis of puerperal infection. If this client is typical of other women with a puerperal infection, which assessment findings are most characteristic? Select all that apply. 1. Pulse rate over 100 beats/minute 2. Complaint of abdominal tenderness 3. A decrease in the size of the uterus 4. Presence of lochia serosa 5. Hematoma on the perineum 6. Continuous trickle of blood from the vagina

12

The nurse proceeds with the assessment, observing the newborn' s reflexes. Which reflexes would the nurse expect to find in a newborn of this gestational age? Select all that apply. 1. Rooting reflex 2. Moro reflex 3. Tonic neck reflex 4. Extrusion reflex 5. Barlow reflex 6. Ortolani reflex

1234

Which of the following observations by the nurse indicate that an appropriate mother-infant bond is occurring? Select all that apply. 1. The mother holds her baby away from her body. 2. The mother makes eye contact with her baby. 3. The mother talks or sings to her baby. 4. The mother discusses the baby's physical attributes. 5. The mother becomes upset because the baby has spit up. 6. The mother repeatedly asks the nurse if the baby is going to live.

234

A 25-year-old primigravid client is in the active phase of the first stage of labor when her membranes rupture. The nurse notes a decrease in the fetal heart tones on the electronic monitor. Upon inspection of the perineum, the nurse observes that the umbilical cord is protruding through the vagina. Which action is most appropriate for the nurse to take initially? 1. Tum the client on the left side. 2. Notify the physician of the findings. 3. Place the client in Trendelenburg position. 4. Prepare a sterile field for delivery of the baby.

3

A 31-year-old client just delivered a healthy baby girl. The nurse tells the father that the infant will receive an injection of vitamin K (AquaMEPHYTON) and erythromycin (Ilotycin ) eye ointment. To meet the infant's priority needs immediately after delivery, which of the following equipment should the nurse have ready? 1. Cord clamp 2. Warm blanket 3. Bulb syringe 4. Oxygen supply

3

A 33-year-old client delivered a healthy infant vaginally 6 hours ago. During the delivery, the physician performed a mediolateral episiotomy. Although in stable condition, the client experiences incisional discomfort. How should the nurse position the client when assessing the perineum after an episiotomy? 1. Prone 2. Supine 3. Sims' position 4. Lithotomy position

3

The placenta is delivered and the physician sutures the episiotomy. The physician instructs the nurse to add oxytocin (Pitocin) to the client's I.V. fluids. The client asks the nurse, "Why do I need this drug?" The nurse explains that oxytocin (Pitocin) is given after delivery of the baby and placenta for which purpose? 1. To increase the blood pressure 2. To prevent the uterus from inverting 3. To decrease the likelihood of hemorrhage 4. To prevent rupture of the uterus

3

When assessing the frequency and duration of the client's contractions during this phase of labor, the nurse expects to find that the contractions are occurring every 3 to 5 minutes and lasting up to how many seconds? 1. 30 2. 40 3. 60 4. 90

3

When the infant's father asks what the purpose of Vitamin K is, the nurse correctly explains that vitamin K (AquaMEPHYTON) is given for what reason? 1. To stimulate respirations 2. To start peristaltic movements 3. To decrease the risk for hemorrhage 4. To increase calcium absorption

3

Which assessment finding is most indicative of fetal distress? 1. Fetal heart rate of 140 beats/minute 2. Presence of fetal heart rate accelerations 3. Presence of green amniotic fluid 4. Increased amount of bloody show

3

Which nursing action best ensures that the thermo-regulation needs of the preterm newborn are being met? 1. The newborn is wrapped in a blanket. 2. The nursery temperature is maintained between 75°F and 79°F (23.9°C and 26.1°C). 3. The newborn is placed in an Isolette or a radiant warmer. 4. The crib is positioned away from sources of drafts.

3

Which observation regarding the delivery of the placenta should the nurse report to the physician? 1. Bulging perineum 2. Shortening of the umbilical cord 3. Rise of the fundus in the abdomen 4. Decreased vaginal discharge

3

A direct Coombs' test is ordered to confirm the diagnosis of hemolytic disease. The nurse should be prepared to assist with the collection of a blood specimen from which source? 1. The newborn's father 2. The newborn's mother 3. The newborn's sibling 4. The newborn's umbilical cord

4

Before leaving the newborn with the parents, the nurse hands the mother a bulb syringe and provides instructions on its proper use. Which statement made by the client indicates a need for additional teaching regarding proper use of the bulb syringe? 1. The mother states that the baby's mouth should be suctioned before the nose is suctioned. 2. The mother states that the bulb syringe should be compressed before it is placed in the baby' s mouth or nose. 3. The mother states that, when suctioning the mouth, the bulb syringe should not touch the back of the baby's throat. 4. The mother states that the bulb syringe should remain compressed until it is removed from the baby's nose or mouth

4

Two hours after a female newborn is delivered at 39 weeks' gestation, the newborn is admitted to the well-baby nursery. The nurse performs a newborn physical assessment and observes normal variations to the skin. Which skin variations are considered normal and require no further intervention? Select all that apply. 1. Mongolian spot 2. Milia 3. Epstein's pearls 4. Erythema toxicum 5. Molding 6. Cephalohematoma

1234

Which of the following clients is at highest risk for developing postpartum hemorrhage? Select all that apply. 1. A client with placenta previa 2. A client who just delivered triplets 3. A client who delivered her sixth baby 4. A client whose fetus had late decelerations 5. A client with a history of primary hypertension 6. A client who had a precipitious delivery

1236

A nurse educator teaches the staff about how to prevent infant abduction from the hospital. A drill is conducted to test the staff's knowledge. Which actions by the hospital staff indicate that they have a good understanding of what to do in case an infant is abducted from the nursery? Select all that apply. 1. Question any person carrying a box or bag. 2. Call the Federal Bureau of Investigation (FBI) immediately. 3. Report suspicious persons to Security STAT. 4. Search closets and stairwells where a baby can be hidden. 5. Thoroughly question all visitors in the hospital. 6. Ask the mother why the baby was left unattended .

134

Four hours after admission to the nursery, the newborn 's condition is stable and there are no signs of distress. The newborn is taken to the mother's room for a visit.When the nurse begins gathering data for a discussion about methods to keep the baby safe while in the hospital, which information should be included in the teaching plan? Select all that apply. 1. Identification bands must be kept on the newborn at all times. 2. When the client is showering, the crib should be placed outside the bathroom door. 3. Hospital staff assigned to the obstetric (OB) department should check the baby's name bands when entering the room. 4. Hospital staff assigned ot the OB department must wear a visible, valid hospital ID. 5. The newborn can sleep in bed with the mother. 6. Visitors coming to the hospital must wash their hands before holding or cruing for the infant.

1346

The client asks the nurse if she will feel any pain while the surgery is performed. Which response by the nurse regarding the client's pain is most appropriate? 1. "You may experience pressure, but you will not feel any pain during the procedure." 2. "You may experience a brief sting when the first incision is made." 3. "You won't remember anything about the procedure because you will be asleep." 4. "You won't feel any pain once the anesthesia takes effect."

1

A 32-year-old client with a history of precipitous labor is admitted to the hospital. She states that contractions are occurring every 2 to 3 minutes. When observing the client's perineum, the nurse notes that the baby's head is crowning. The nurse is alone with the client and unable to obtain assistance. At this point, what is most appropriate for the nurse to do after putting on sterile gloves? 1. Gently place one hand on the crowning head, and allow the head to emerge slowly between contractions. 2. Push back firmly on the head, and place pressure on the vaginal meatus until the physician arrives. 3. Place a sterile towel over the perineal area, and have the client bring the legs close together. 4. Slide a finger into the vagina, and enlarge its exit while delivering the head during a contraction.

1

A 38-year-old multiparous client gave birth a day ago to a full-term newborn with a myelomeningocele. Which assessment finding best indicates that the client is grieving over the loss of a "perfect" baby? 1. The client has not selected a name for the baby. 2. The client visits the nursery frequently but only stays for a few minutes. 3. The client asks the physician to postpone discharge from the hospital. 4. The client leaves the nursery when the baby receives treatments.

1

A newborn is born at 27 weeks' gestation and is taken to the Neonatal Intensive Care Unit (NICU) at a nearby hospital in respiratory distress. Which nursing intervention is essential for preventing retinopathy of prematurity (ROP) in the preterm newborn? 1. Monitor the oxygen concentration level. 2. Monitor the bilirubin level. 3. Check the hemoglobin level. 4. Check the pupil response.

1

A newborn is delivered at 32 weeks' gestation to a gravida I, para I human immunodeficiency virus (HIV)-positive mother. When providing care for this newborn, the nurse should follow which precautions? 1. Standard precautions 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

1

After a sterile vaginal examination is performed, the client tells the nurse, "I overheard the physician say that the baby is in the vertex position. What does this mean?" Which response by the nurse provides the best explanation regarding vertex positioning? 1. "The head is entering the birth canal first." 2. "The feet are entering the birth canal first." 3. "The buttocks are entering the birth canal first." 4. "The shoulder is entering the birth canal first."

1

After the membranes have ruptured, how often should the nurse take the client's temperature? 1. Every hour 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours

1

At which location can the nurse expect to palpate the fundus of the uterus immediately after delivery? 1. At or just below the level of the umbilicus 2. Just above the level of the umbilicus 3. Just above the level of the symphysis pubis 4. Midway between the umbilicus and symphysis pubis

1

Because the nitrazine test results indicate that the membranes have ruptured, the physician orders internal electronic fetal monitoring. The client asks the nurse, "ls there any danger of this procedure causing harm to my baby?" Which response by the nurse provides the best explanation of internal electronic fetal monitoring? 1. "The procedure requires attachment of a small spiral electrode to the fetal scalp and poses a slight risk of soft tissue injury and infection." 2. "The procedure requires insertion of a soft, water-filled catheter into the uterus and poses no risk of injury to you or your baby." 3. "The procedure requires placement of an ultrasound transducer over your abdomen and poses no risk to you or your baby." 4. "The procedure requires application of a suction cup to the fetal scalp and poses a slight risk for the development of a hematoma."

1

Before discharge, the nurse prepares to perform a phenylketonuria (PKU) test. Which information is most important for the nurse to assess before performing the PKU test? 1. Whether the newborn has been feeding for at least 2 to 3 days 2. Whether the newborn was large for the gestational age at birth 3. Whether the mother had gestational diabetes during the pregnancy 4. Whether there is a family history of mental retardation

1

The client asks the nurse how long after discharge sexual intercourse should be delayed. The nurse best explains that sexual intercourse may be resumed at which time? 1. As soon as the lochia has ceased and the perineum is healed 2. As soon as an acceptable birth control method is selected 3. After the postpartum checkup in 4 to 6 weeks 4. After the uterus has returned to its normal position

1

The client informs the nurse about a previous admission to the unit 3 days ago with "false labor." Which statement made by the client indicates an understanding of Braxton Hicks contractions? 1. "The contractions are less strong when I walk." 2. "The contractions are regular and I can time them." 3. "The contractions get stronger no matter what I am doing." 4. "The contractions start in my lower back."

1

The client is transferred to the operating room. The physician plans to perform a lower-segment transverse incision and requests that the nurse perform the surgical skin preparation. Which method of cleansing the abdomen is most appropriate? 1. The nurse cleanses the entire abdomen beginning at the level of the nipple line. 2. The nurse cleanses the entire abdomen beginning at the top of the uterine fundus. 3. The nurse cleanses the entire abdomen beginning at the level of the umbilicus. 4. The nurse cleanses the entire abdomen beginning 6 in. (15 cm) above the mons pubis.

1

The client tells the nurse, "I think my membranes have ruptured. " The nurse performs a nitrazine test and confirms that the membranes have ruptured. Which test result indicates that the membranes have ruptured? 1. The test strip turns blue. 2. The test strip turns yellow. 3. The test strip turns red. 4. The test strip turns green.

1

The client tells the nurse, "I'm disappointed that it was necessary to have a delivery by cesarean section," then asks the nurse, "If I have another baby, will I have to have another cesarean?" Which response by the nurse is most accurate regarding a vaginal birth after a cesarean birth (VBAC)? 1. "It may be possible to have a VBAC if the previous cesarean incision was a classical incision ." 2. "A vaginal birth is not recommended after a cesarean birth because of the danger of uterine rupture." 3. "A vaginal birth is just as painful as a cesarean birth because an episiotomy has to be performed." 4. "A VBAC may be possible if there is no history of medical conditions that prohibit it."

1

The client thinks it is best to give the baby formula until breast milk comes in. She tells the nurse, "I started to breast-feed my first child, but changed to bottle-feeding because the baby lost lots of weight before being discharged from the hospital. " Which response by the nurse is most appropriate regarding neonatal weight loss? 1. "It's normal for both bottle-fed and breast-fed infants to lose up to 10% of their birth weight during the first few days after birth." 2. "If your baby begins bottle-feeding, the infant won't be successful breast-feeding because of a preference for the bottle nipple." 3. "A baby is more prone to lose weight with bottle-feeding than breast-feeding because formula is more difficult to digest" 4. "Until the baby is ready to begin breast-feeding, you should pump your breasts to promote the letdown reflex."

1

The day after surgery, the client complains of abdominal pain and bloating. The nurse notes that the client 's abdomen is distended. Which intervention is most appropriate to relieve the client's discomfort? 1. Assist the client to ambulate in the hall. 2. Insert a rectal tube to monitor bowel function. 3. Administer the prescribed pain medication. 4. Instruct the client to use a straw when drinking fluids.

1

The father of a toddler brings the child to the hospital to see the newborn sibling. The toddler acts out and throws the newborn 's pacifier onto the floor. The parents are embarrassed about their toddler's behavior. Which parental advice regarding sibling rivalry is most appropriate at this time? 1. After going home, each parent should spend time with the toddler doing activities the toddler enjoys. 2. The toddler should be sent to a grandparent's for the first week until a routine can be established with the newborn. 3. Set firm limits on the toddler's behavior providing appropriate discipline and punishment. 4. Keep the toddler and the newborn separated for the first few days until the toddler can adjust to the new sibling.

1

The infant' s father also wants to know about the ointment that is being placed in the baby's eyes. The nurse explains to the father that erythromycin (Ilotycin) is given to protect the infant from neonatal blindness, which can occur if the infant develops an eye infection caused by which organisms? 1. Gonococcal and chlamydial organisms 2. Gonococcal and streptococcal organisms 3. Gonococcal organisms and Candida albicans 4. Gonococcal organisms and Pneumocystis carinii

1

The infant' s total bilirubin level is 11 mg/dL. The physician orders phototherapy. When providing care for a newborn receiving phototherapy, which nursing intervention is most appropriate? 1. The nurse covers the infant's eyes when providing treatment. 2. The nurse feeds the newborn through the nasogastric route. 3. The nurse maintains the newborn in the supine position. 4. The nurse monitors the l.V. infusion site at least every 2 hours.

1

The nurse assesses for which complication during the immediate postprocedural period? 1. Maternal hypotension 2. Fetal tachycardia 3. Spinal headache 4. Lower extremity paralysis

1

The nurse cares for a 30-year-old multiparous client who is in the transition phase of the first stage of labor. Which assessment finding best indicates that the client has entered the second stage of labor? 1. The perineum is bulging. 2. Contractions are lasting 30 to 60 seconds. 3. The cervix is dilated to 8 cm. 4. The client becomes agitated with her spouse.

1

The nurse correctly instructs the client to notify the healthcare provider if what occurs? 1. The client experiences difficulty urinating. 2. The lochia becomes creamy yellow after the first postpartum week. 3. The client experiences unexplained feelings of tearfulness and sadness. 4. The client's breasts become slightly firm after 48 hours.

1

The nurse correctly massages the fundus by placing one hand on the fundus and the other hand where? 1. Just above the symphysis pubis 2. To the right side of the abdomen 3. Just below the xiphoid process 4. To the left side of the abdomen

1

The nurse instructs the mother about initial breast-feeding. The client says to the nurse, "My breasts are small. Will I be able to breast-feed my baby?". Which response by the nurse is most appropriate? 1. "The size of your breasts does not affect your ability to breast-feed ." 2. "You should attempt to breast-feed and give supplemental formula." 3. "Bottle-feeding is just as nutritious as breast-feeding." 4. "You can do exercises to increase the size of your breasts."

1

The obstetrician prepares for delivery and requests that the client be prepared for epidural anesthesia. The nurse is aware that, the epidural anesthetic will take how long to become effective? 1. Immediately 2. In 10 to 20 minutes 3. In 30 to 40 minutes 4. In approximately 1 hour

1

The patient care technician assists the client with perineal hygiene. Which observation by the nurse indicates that the technician needs additional instruction? 1. The technician applies the peripad from back to front. 2. The technician wears gloves while providing perineal care. 3. The technician fills the peri bottle with warm tap water. 4. The technician uses a hand sanitizer before giving perineal care.

1

The pediatrician writes orders for the newborn to be discharged if no complications occur within 4 hours of the circumcision. Before discharge, the nurse reviews home care of the circumcision. Which statement by the parents indicates that teaching has been effective? 1. "We'll notify the pediatrician if we see any drainage from the baby's penis." 2. "We'll clean the baby's penis three times a day with alcohol." 3. "We'll remove the Plastibell ring in 1 week if it has not fallen off by then." 4. "We'll apply petroleum jelly to the baby's penis with each diaper change."

1

When should the nurse begin delivery preparation s for this client? 1. When the client is about 7 cm dilated 2. When the fetal head begins to crown 3. When the physician or midwife arrives 4. When the client is completely dilated

1

Which assessment finding would the nurse consider most indicative of congenital hip dysplasia in a newborn? 1. Asymmetry of the gluteal skin folds 2. Limited adduction of the affected hip 3. No spontaneous movement of the affected leg 4. Exaggerated curvature of the lumbar spine

1

Which intervention is most important for the nurse to implement before transporting the newborn from the delivery area to the nursery? 1. Placing matching identification bracelets on mother and baby 2. Administering prophylactic eye medication 3. Giving I.M. vitamin K (AquaMEPHYTON) 4. Obtaining a blood sample for phenylketonuria (PKU) testing

1

When the nurse documents the following newborn profile information on the flow sheet, which data require notifying the pediatrician immediately? Select all that apply. 1. Head circumference of 20 in. (50 cm) 2. Chest circumference of 13 in. (33 cm) 3. Length of 19 1/2 in. (50 cm) 4. Heart rate of 100 beats/minute 5. Weight of 11 pounds (5 kg) 6. Abdominal circumference of 11 1/2 in. (30 cm)

145

When performing postpartal checks just after delivery, which assessment findings should the nurse report immediately? Select all that apply. 1. A pulse rate between 120 and 130 beats/minute 2. Presence of dark red, fleshy-smelling lochia 3. Saturation of one pepneal pad per hour 4. A systolic blood pressure less than 90 mm Hg 5. A respiratory rate of 24 breaths/minute 6. Cool, clammy skin

146

A 26-year-old gravida I client is admitted to the hospital in active labor. During the physician's examination, it is determined that the client has cephalopelvic disproportion. A cesarean birth using epidural anesthesia is scheduled. The physician orders the insertion of an indwelling urinary catheter before surgery. The client asks the nurse, "Why do I need a urinary catheter?" Which response by the nurse regarding the placement of the indwelling catheter is most accurate? 1. "It prevents the development of postpartum hemorrhaging." 2. "It keeps the bladder empty during the surgical procedure." 3. "It's used as a landmark for the physician during surgery." 4. "It's inserted to provide a safe way of collecting urine specimens."

2

A 26-year-old primigravid client at 40 weeks' gestation is admitted to the hospital after contacting the physician about not having felt the baby move for 24 hours. The nurse is unable to detect a fetal heartbeat using the external fetal monitor. The physician examines the client and determines that the fetus is dead. An infusion of oxytocin (Pitocin) is ordered for induction of labor. The client is crying and tells the nurse, "This can't be true. You must have made a mistake. " Which nursing intervention is most appropriate at this time? 1. Recheck the fetal heart tones with the electronic external fetal monitor so that the client can listen. 2. Express sorrow about the client's loss and encourage the client to express feelings. 3. Redirect the client's attention to the laboring process and the correct use of breathing techniques. 4. Explain that the baby probably would have been born with severe long-term health problems.

2

After instillation of the eye ointment, the nurse informs the father that the baby may experience which of the following? 1. Swelling of the eyes 2. Temporary blurred vision 3. Purulent eye drainage 4. Conjunctival hemorrhage

2

After the bath is completed, the nurse rechecks the newborn 's axillary temperature and records it as 97°F (36.1°C). Which nursing intervention is most appropriate at this time? 1. Dress and wrap the newborn in a blanket, place in an open crib, and recheck the temperature every 4 to 8 hours. 2. Place the newborn on a preheated radiant warmer, and gradually rewarm over a period of 2 or more hours. 3. Dress the newborn, wrap in double blankets, place in an open crib, and recheck the temperature in 30 to 60 minutes. 4. Place the newborn on a preheated radiant warmer, and rewarm over a period of 15 to 30 minutes.

2

During the initial assessment, the nurse notes that the client' s fundus is one fingerbreadth above the umbilicus and displaced to the right of the abdominal midline. Which action is most appropriate for the nurse to take in response to this finding? 1. Assist with repositioning the client onto the left side. 2. Have the client void, and recheck the uterus afterward. 3. Massage the fundus until it becomes firm and returns to its normal position. 4. Document the findings and continue to check the fundus at least every 8 hours

2

Six hours after admission to the nursery, the newborn is taken to the mother for the first feeding. The mother wants to bottle-feed the newborn. The nurse reviews basic principles of bottle-feeding with the mother. Which observation by the nurse indicates that the client has an incorrect understanding of the basic principles of bottle-feeding? 1. The mother places the nipple of the bottle on top of the baby's tongue. 2. During feeding, the mother places the baby in the supine position. 3. The mother burps the baby after taking each ounce of formula. 4. The mother places the baby in the right side-lying position after feeding.

2

The baby is delivered stillborn. Following stabilization, the client is transferred to a pr ivate room on a wing adjacent to the labor, delivery, recovery, and postpartum (LDRP) unit. The client's husband is present. The client asks the nurse about seeing the baby. Which action is most appropriate for the nurse to take at this time? 1. Substitute a memory packet, including such items as a picture of the baby and footprints. 2. Bring the infant and allow the couple to view the baby privately . 3. Encourage the client to postpone viewing the baby until after having had an opportunity to receive counseling. 4. Bring the infant, but do not allow the parents to hold or touch the infant.

2

The client arrives at the hospital and is admitted to the labor, delivery, recovery, and postpartum (LDRP) unit. The nurse obtains the client's health and pregnancy history. As the nurse collects the client's history, which question has the lowest priority? 1. "When did you last eat?" 2. "Have you ever had an enema?" 3. "When did your contractions start?" 4. "When is your baby due?"

2

The client asks the nurse, "How will I know that my baby is getting enough to eat?" Which action would most likely occur in a newborn whose nutritional needs are not being adequately met? The nurse explains that which action would most likely occur in a newborn whose nutritional needs are not being adequately met? 1. Awakening during the night for a feeding 2. Having fewer than six wet diapers per day 3. Having loose, pale-yellow stools 4. Breast-feeding every 2 to 3 hours

2

The client tells the nurse about plans to continue breast-feeding after returni"ng to work and to pump both breast when unable to breast-feed. The client asks the nurse, "How long can I store the breast milk that I pump?. ". The nurse correctly responds that breast milk can be safely stored in the refrigerator for how long after pumping? 1. Up to 4 hours 2. Up to 2 days 3. Up to 1 week 4. Up to 1 month

2

The client tells the nurse, "I plan to have an epidural for pain management," and asks the nurse, "When can I expect to receive it?" An epidural is best performed when the client is how many centimeters dilated? 1. 3 to 4 2. 5 to 6 3. 7 to 8 4. 9 to 10

2

The nurse also explains that during the first few days after the newborn's birth, the client's breasts will secrete colostrum, which is beneficial to the baby because it contains which substance? 1. Estrogen, which will prevent the newborn from developing breakthrough bleeding 2. Antibodies, which provide protection against certain types of infections 3. Predigested fats, which increase the newborn' s ability to absorb fat-soluble vitamins 4. Digestive enzymes, which increase the newborn's ability to absorb nutrients

2

To best facilitate mother-infant attachment and prevent the newborn from developing distress, what should the nurse do initially? 1. Give the newborn to the mother immediately after initial care is given in the delivery room. 2. Immediately dry the newborn, then place the infant skin-to-skin on the mother's abdomen. 3. Place the newborn in a radiant warmer for 5 minutes, then wrap the newborn and give the infant to the mother. 4. Place the newborn in the radiant warmer, and position the warmer so the mother can see the infant.

2

Twenty-four hours after delivery, the obstetrician writes discharge orders. The nurse reviews home care instructions with the client in anticipation of the discharge. After the nurse instructs the client about ways to avoid constipation, which statement made by the client indicates a need for additional teaching? 1. "I should drink at least 2 to 3 quarts of fluid daily ." 2. "I will need to take a stool softener every other day ." 3. "I should include raw fruits and vegetables in my diet." 4. "I will need to continue taking daily walks."

2

When administering Rho(D) immune globulin (RhoGAM) to an Rh-negative mother who has delivered an Rh-positive infant, what is the maximum length of time the nurse has to give the medication? 1. 48 hours after delivery 2. 72 hours after delivery 3. At the 6-week postpartum checkup 4. Within the first 24 hours of delivery

2

When is it necessary for the nurse to withhold the terbutaline sulfate (Brethine) and notify the physician ? 1. When the electronic monitor reveals that the client is having mild contractions 2. When the cervix is dilated 4 cm or greater or effaced 50% or more 3. When the electronic monitor reveals the presence of fetal heart rate variability 4. When the client states that the contractions are milder and occurring less frequently

2

When the newborn is 3 days old, the nurse observes that the skin is slightly yellow. The nurse correctly documents the infant's skin color using which term? 1. Mottled 2. Jaundiced 3. Acrocyanotic 4. Erythematous

2

Which action by the nurse best facilitates the client's acceptance and care of the newborn with a myelomeningocele? 1. Show the client "before" and "after" pictures of other infants born with myelomeningocele. 2. Serve as a role model by feeding, holding, and changing the newborn in the client's presence. 3. Explain to the client that surgery will most probably eliminate the defect and its consequences. 4. Assure the client that social agencies will most likely assume full care of the newborn.

2

Which assessment finding would the nurse consider abnormal for this newborn? 1. A scrotal sac that has numerous rugae 2. An umbilical cord that has one vein and one artery 3. Vernix caseosa in the creases of the groin area 4. Bluish discoloration of the hands and feet

2

Which finding would the nurse consider abnormal for the postpartum client who delivered within the last 24 hours? 1. The client has passed a couple of nickel-sized clots. 2. The client has calf pain when a foot is dorsiflexed. 3. The client has abdominal cramping while breast-feeding. 4. The client's vaginal discharge is dark red.

2

After 2 days of therapy, the newborn 's total bilirubin level decreases to 9 mgldL and phototherapy is discontinued. The pediatrician prepares for a circumcision using the Plastibell technique. Following the circumcision, which nursing action is most appropriate? 1. Maintain a petroleum gauze dressing over the penis. 2. Monitor the vital signs every 15 minutes for the first hour. 3. Frequently monitor the penis for swelling and bleeding. 4. Place the newborn on the abdomen.

3

After the newborn' s respiratory condition stabilizes and the infant is weaned from the ventilator, the neonatologist writes an order to begin feedings. When feeding the preterm newborn, which method is most appropriate? 1. Feed the infant every hour around the clock. 2. Give the infant no more than 3 to 4 ounces per feeding. 3. Feed the infant with a nasogastric tube. 4. Give the infant glucose solution for the first month.

3

During the latent phase of the first stage of labor, how often should the nurse plan to assess the fetal heart rate? 1. Every 5 minutes 2. Every 15 minutes 3. Every 30 minutes 4. Every 60 minutes

3

How often should the nurse assess fetal heart rate during the active phase of labor? 1. Every 5 minutes 2. Every 10 minutes 3. Every 15 minutes 4. Every 30 minutes

3

Labor has progressed, and the client enters the transition phase of the first stage of labor. "Which assessment finding can the nurse expect to observe during this phase? 1. Cervix dilated to 10 cm 2. Crowning of the presenting part 3. Increased bloody show 4. Contractions lasting up to 60 seconds

3

The cesarean birth is performed without complications. About 1.5 hours after surgery, the client is transferred in stable condition to the postpartum unit. The abdominal dressing is dry and intact, the indwelling catheter is patent and draining clear yellow urine, and I.V. fluids are infusing at the prescribed rate. The client also has a continuous infusion of epidural morphine sulfate. While the client is receiving epidural morphine sulfate, the nurse closely monitors the client for which adverse reaction? 1. Urinary incontinence 2. Pupil dilation 3. Respiratory depression 4. Elevated blood pressure

3

The client asks the nurse about breast-feeding the baby. Which explanation by the nurse is most appropriate regarding breast-feeding this newborn? 1. "It's OK to breast-feed the baby if the anti-HIV test results are positive ' 2. "It's OK to breast-feed the baby as long as he is symptom-free." 3. "You can't breast-feed the baby because you are HIV-positive." 4. "You can't breast-feed the baby if you have developed symptoms of AIDS."

3

The client complains of pain and asks the nurse, "Can I have some more Stadol?" The nurse correctly explains that butorphanol tartrate (Stadol) is not given at this time because opioid analgesics during this stage of labor may have which effect? 1. Decrease the effectiveness of the contractions 2. Cause the uterus to rupture 3. Result in respiratory depression in the newborn 4. Cause increased fetal activity

3

The client informs the nurse about plans to continue breast-feeding after being discharged and asks what should be done about breast engorgement if it occurs at home. Which nursing instruction is most appropriate regarding breast engorgement? 1. "Pump your breasts between breast-feedings ." 2. "Limit your fluid intake for 24 hours." 3. "Feed your baby every 2 to 3 hours." 4. "Apply ice packs to your breasts four times per day."

3

The client tells the nurse, "I feel like I need to push. " Which action should the nurse take initially? 1. Instruct the client to push when feeling the next contraction. 2. Ensure that the client is in semi-Fowler's position. 3. Ensure that the client's cervix is fully dilated. 4. Instruct the client to take a cleansing breath before pushing.

3

The client's husband asks the nurse if he can remain with his wife during the cesarean birth. Which statement by the nurse is most appropriate in response to the husband's request? 1. "Only your wife and surgical personnel are allowed in the operating room to maintain a sterile environment." 2. "You can join your wife in the operating room only after the baby has been delivered and your wife and baby are stable." 3. "You can join your wife in the operating room after you change into the appropriate attire." 4. "You can join your wife at the time of transfer to the recovery area and the effects of the anesthesia have worn off."

3

The mother asks the nurse when the baby will be tested for HIV, and how long it usually takes before HIV-positive babies develop acquired immunodeficiency syndrome (AIDS). Which statement by the nurse about HIV testing is most appropriate? 1. "Your baby won't be tested because babies of HIV-positive mothers are already HIV-positive." 2. "Your baby will be tested immediately for anti-HIV antibodies to facilitate early treatment." 3. "Your baby won't be tested for anti-HIV antibodies until 3 months of age." 4. "Your baby will be tested for anti-HIV antibodies for 4 years or until test results are positive."

3

The mother tells the nurse of a plan to use concentrated liquid infant formula at home. The nurse gathers information about formula preparations and reviews this with the parents. Which statement made by the mother indicates a need for additional teaching? 1. "I can wash the formula bottles in a dishwasher." 2. "I should use warm tap water to dilute the concentrate." 3. "The formula should be used immediately after it is prepared." 4. 'The lid of the can of formula must be wiped before it is opened."

3

The nurse gives the mother verbal instructions about how to breast-feed correctly. The nurse then remains in the room to assist the mother. Which action by the client indicates a need for additional teaching regarding proper breast-feeding technique? 1. The mother uses the thumb of the free hand to gently press the breast away from the baby's nose. 2. The mother gently strokes the baby's lips with the nipple when ready to breast-feed. 3. The mother places a breast shield over the nipple before placing the nipple in the baby's mouth. 4. The mother gently pulls down on the baby's chin before removing the nipple from the baby's mouth.

3

The patient care technician weighs the newborn. Which action by the technician indicates a need for additional teaching regarding accurate and safe assessment of the newborn' s weight? 1. The technician undresses the newborn before obtaining the weight. 2. The technician places a diaper or paper barrier on the scale before balancing it. 3. The technician keeps one hand on the newborn while obtaining the weight. 4. The technician cleans the scale with an antiseptic before using it

3

The physician informs the client that she needs to have an episiotomy. The client begins to cry and asks the nurse, "Why do I have to have an episiotomy?" Which response by the nurse best explains the need for an episiotomy? 1. "An episiotomy is necessary to prevent uterine rupture." 2. "An episiotomy is necessary to prevent postpartum infection." 3. "An episiotomy is necessary to prevent perineal laceration." 4. "An episiotomy is necessary to prevent rectal trauma."

3

After the newborn's temperature has stabilized, the nurse gives the first bath. Which findings noted by the nurse bathing the newborn should be reported immediately? Select all that apply. 1. The hands and feet are bluish in color. 2. The pulse rate is 140 beats/minute. 3. The skin has a yellowish discoloration. 4. The labia are slightly swollen. 5. There is nasal flaring. 6. Substemal and intercostal retractions are noted

356

A gravida II, para I client in the 38th week of pregnancy comes to the emergency department in active labor. An Rh-positive newborn is delivered with congenital hemolytic disease caused by Rh incompatibility. Which assessment finding is most indicative of the presence of Rh incompatibility? 1. A slow and irregular respiratory rate 2. Absence of newborn reflexes 3. Limited movement in the lower extremities 4. Jaundice within 24 to 36 hours of birth

4

A postterm male newborn in no apparent distress is admitted to the nursery after an uneventful planned cesarean birth. During an initial assessment, the nurse would expect to note which finding that is characteristic of a postterm newborn? 1. Few sole creases 2. Flat, shapeless ears 3. Legs in a frog-like position 4. Dry, cracked, leatherlike skin

4

After the vaginal examination, the physician indicates that the client is in the latent phase of the first stage of labor. A progress note is written in the client's admission records. When the nurse reviews the client's admission records, which assessment finding is the most reliable indicator that the client is in true labor? 1. Contractions are regular and increasing in duration and intensity. 2. Contractions radiate from the lower back to the lower abdomen. 3. Bloody show is present. 4. The cervix is dilating.

4

During evaluation of the client's contractions during the active phase of the first stage of labor, when is it important for the nurse to notify the physician? 1. When the contractions occur every 3 to 5 minutes 2. When the contractions last longer than 45 seconds 3. When the uterus relaxes between contractions 4. When the fetal heart rate drops after the acme of a contraction

4

During the admission process, the nurse obtains the client 's vital signs. When is the most appropriate time to take the client's vital signs? 1. At the peak of a contraction, with the client positioned on the left side 2. At the peak of a contraction, with the client positioned on the right side 3. Between contractions, with the client positioned on the right side 4. Between contractions, with the client positioned on the left side

4

It would be correct for the nurse to explain that most children who contract HIV in utero typically develop AIDS symptoms at which age? 1. At birth 2. By age 6 months 3. By age 12 months 4. By age 2 years

4

The client continues in active labor and tells the nurse, "I haven't had anything to eat for 24 hours. Can I have something to eat now?" Which response by the nurse best explains why solid food is not given at this time? 1. "It may alter the absorption of regional anesthetics." 2. "It may alter the duration and frequency of contractions." 3. "It may cause fetal distress." 4. "It may cause nausea and vomiting ."

4

The client tells the nurse about feeling the urge to urinate but being unsuccessful. Which nursing action is most appropriate to implement initially? 1. Catheterize the client with a straight catheter. 2. Assist the client with ambulation. 3. Have the client drink more fluids. 4. Assist the client with a warm sitz bath.

4

The mother asks the nurse why it is important to keep the bottle nipple full of formula. Holding the bottle so that the nipple is always full of formula helps prevent which complication in the newborn? 1. Damaging his gums 2. Getting tired while feeding 3. Regurgitating the formula 4. Swallowing air when sucking

4

The newborn is assigned an Apgar score of 7 at 5 minutes. On the basis of the baby's Apgar score, the nurse anticipates providing care for a newborn in what condition? 1. Severely distressed 2. Moderately distressed 3. Stable but requiring close monitoring 4. Vigorous with no signs of distress

4

The newborn' s father asks about positioning the baby in the crib after his wife finishes breast-feeding. The nurse correctly explains that it is best to place the newborn in which position in the crib after feeding? 1. Right side-lying 2. Left side-lying 3. Prone 4. Supine

4

The nurse observes the client for signs of impending delivery of the placenta. To facilitate delivery of the placenta, what should the nurse instruct the client to do? 1. Tum on the right or left side. 2. Breathe slowly and deeply. 3. Tighten and relax the perineum intermittently. 4. Push when feeling a contraction occurring.

4

To prevent distension of the client's bladder during the active phase of labor, which nursing intervention is most appropriate? 1. Instructing the client to limit fluid intake 2. Decreasing the rate of the I.V. infusion 3. Offering solid foods instead of liquids 4. Encouraging the client to void every 2 hours

4

To prevent hemorrhage, when should the nurse massage the fundus during the postpartal period? 1. When the fundus is firm and hard 2. When the fundus is at the umbilicus 3. When the amount of lochia decreases 4. When the fundus is soft and boggy

4

Twenty-four hours after surgery, the physician writes orders to discontinue the morphine epidural, I.V. therapy, and indwelling catheter and to administer propoxyphene and acetaminophen (Darvocet N 50) 2 tabs P.O. every 3 to 4 hours p.r.n.for pain. The physician also removes the abdominal dressing and says the client may shower and ambulate as tolerated. Which assessment finding best indicates the presence of infection of the abdominal incision line? 1. The client states that the incision line feels numb. 2. The client's oral temperature is 99°F (37.2°C). 3. The incision line is approximated. 4. The incision line is red and swollen.

4

When obtaining the blood specimen for the PKU test, which action by the nurse is incorrect? 1. Warm the newbom's heel for 5 to 10 minutes. 2. Obtain the appropriate card for the blood sample. 3. Discard the first drop of blood obtained. 4. Apply pressure afterwards with an alcohol swab.

4

When the client tells the nurse, "I'm nervous about going home with the new baby," which nursing action is most appropriate? 1. Suggest that the client ask the physician to postpone discharge. 2. Tell the client that this is a normal feeling that will go away in time. 3. Make sure the client has written instructions on infant care before discharge. 4. Provide the facility's telephone number with encouragement to call as needed.

4

Which medication should the nurse plan to have readily available while the client is receiving epidural morphine sulfate? 1. Buprenorphine hydrochloride (Buprenex) 2. Calcium gluconate (Calsan) 3. Atropine sulfate (Atropair) 4. Naloxone hydrochloride (Narcan)

4