CHAPTER 15 - FEMALE REPRODUCTIVE, MATERNITY & NEWBORNS

A woman, gravida 2, para 2, term 2, preterm 0, abortion 0, living 2, who has just had an unexpected cesarean delivery asks the nurse if having a cesarean means that she cannot have any more children. What is the best response for the nurse to give this mother? 1. "Many women are able to have another child after having had a cesarean delivery." 2. "Since you have two healthy children, it would be better not to attempt another delivery." 3. "Is it important for you to have more children?" 4. "That is a question you will have to discuss with your physician."

1. A cesarean delivery is not in itself a contraindication for another pregnancy. Many women can have a vaginal delivery after a cesarean. The old rule of only two cesarean deliveries is no longer true. Remember that this client had one vaginal delivery and one cesarean. Answer 2 does not give accurate information. Answer 3 does not answer the question. Answer 4 contains some truth, but the nurse should be able to give general information to this mother.

At 3 hours of age, a term newborn seems jittery and has a weak and high-pitched cry and irregular respirations. The nurse suspects that the infant may have which of the following? 1. Hypoglycemia 2. Hypercalcemia 3. Hypervolemia 4. Hypothyroidism

1. Being jittery and having a weak and high- pitched cry and irregular respirations are classic symptoms of hypoglycemia.

The nurse is caring for a woman in labor who is having contractions every five to seven minutes that last 45 to 50 seconds. Her husband asks if this is transition because his wife is getting restless and irritable and feels pressure. What is the best response for the nurse to make? 1. "Transition is still a long way off. Don't you remember this from your classes?" 2. "Her contractions are not typical of transition, but I'll have the RN check her." 3. "The contractions are typical of transition. You are very observant." 4. "It's impossible to tell where she is without doing an exam."

2. Contractions during transition usually occur every two to three minutes and last 60 to 90 seconds. Her contractions are not typical of transition, but the only way to be sure is to have the RN do a vaginal exam. Answer 1 ignores the symptoms and puts the client down. Answer 3 is incorrect information; her contractions are not typical of transition. Irritability and restlessness can be signs of transition. Answer 4 is not a useful response. It is not completely true, and it is certainly not a therapeutic response.

A baby boy was born at 2:45 A.M. after a 35-week gestation. He weighed 1170 g. Upon admission to the premature nursery, he had slight respiratory distress, nasal flaring, grunting, intercostal retractions, and slight cyanosis. Apgar score at one minute was 4, and at five minutes, it was 6. Apical pulse is 164, respirations are 44, and axillary temperature is 96°F. What was the most likely cause of the baby's cyanosis? 1. Increased serum concentration of bilirubin 2. Inadequate oxygenation of arterial blood 3. Excessive number of red blood cells 4. Lack of subcutaneous fatty tissue

2. Cyanosis is indicative of inadequate oxygenation. Increased bilirubin would be evidenced by jaundice. It is normal for newborns to have excessive red blood cells. This does not cause cyanosis. Lack of subcutaneous fatty tissue is common in premature infants and causes poor temperature regulation.

The nurse is caring for a laboring woman who has a history of rheumatic heart disease. How should the nurse position her during labor? 1. Supine 2. Semi-recumbent 3. Side-lying 4. Sitting

2. Semi-recumbent or semi-sitting position would be the most appropriate position to reduce the cardiac work load and ease breathing. The laboring woman who has a history of rheumatic heart disease is at risk for congestive heart failure. The supine and side-lying positions would increase the cardiac work load. Sitting upright is not the best choice.

Which finding, if present, would suggest to the nurse that the infant was not at term when born? 1. The scrotum has rugae. 2. Testicles are not descended. 3. Scanty vernix 4. Sparse lanugo

2. Testicles normally descend into the scrotum at eight months gestation. An infant born prior at that time will have undescended testicles. A term infant will have rugae on the scrotum. Vernix and lanugo are less with a term infant than with a premature infant.

What is the most common complication associated with too rapid delivery in precipitate labor? 1. Pitting edema of the baby's scalp 2. Dural or subdural tears in fetal brain tissue 3. Premature separation of the placenta 4. Prolonged retention of the placenta

2. The sudden change of pressure tends to tear away dural linings. The mother can also get perineal tears. Answer 1 is not correct. Edema of the scalp is not a complication with precipitate labor. Sometimes prolonged labor can cause caput succedaneum, where the baby has bleeding under the scalp. Answers 3 and 4 are not correct. Rapid delivery is not particularly associated with placental problems.

The nurse is caring for a woman who delivered a healthy infant via cesarean delivery 30 minutes ago. The mother says to the nurse, "Please don't touch my belly. I had an operation." What is the nurse's best response? 1. "Alright I won't. Be sure to let me know if you have any pain or bleeding." 2. "I do need to look at your abdomen to check your incision." 3. "I must touch your abdomen to check you uterus, but I won't touch your incision." 4. "I can wait two more hours before I will need to check your uterus."

3. A woman who had a cesarean delivery still needs to have the uterine fundus checked for firmness and massaged if it is not firm. This is usually done every 15 minutes for the first two hours after delivery. The uterine fundus is well above the incision site, so it is not necessary to touch the incision. The nurse should inspect the dressing for bleeding.

A woman, 38 weeks pregnant, arrives in the labor and delivery suite and tells the nurse that she thinks her membranes have ruptured. The nurse uses phenaphthazine (Nitrazine) paper to test the leaking fluid. The nurse expects the Nitrazine paper to turn which color if amniotic fluid is present? 1. Red 2. Orange 3. Blue 4. Purple

3. Amniotic fluid is alkaline and turns Nitrazine paper blue. Urine is acidic and turns Nitrazine paper red.

What should the nurse do to stimulate the separation of the placenta after home delivery of a baby? 1. Ask the mother to push down vigorously 2. Push the fundus down vigorously 3. Encourage the baby to breastfeed 4. Place gentle tension on the umbilical cord

3. Breastfeeding stimulates uterine contractions, which will help the placenta to separate. Answer 1 is not correct. Having the mother push down vigorously will not stimulate the placenta to separate. Answer 2 is not correct. The nurse should not push down on the fundus. This is not necessary for the placenta to separate. Answer 4 is not correct. The nurse should never pull on the cord. This could cause inversion of the uterus.

The nurse is caring for a woman who has had a spinal anesthetic. Which of the following would be most likely to occur after spinal anesthesia? 1. The client states that she is dizzy and light- headed. 2. The temperature is 101°F. 3. The nurse observes the client shivering. 4. The client develops a red, itchy rash on her back and chest.

3. Chills occur frequently after the administration of a regional anesthetic such as Carbocaine. A spinal anesthetic does not usually cause the client to be dizzy and light-headed. Fever and rash are not likely to occur after spinal anesthesia.

At one minute after birth, an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps his arms extended and his legs flexed. What is the Apgar score? 1. 4 2. 6 3. 8 4. 10

3. He receives 2 points for respiratory effort because he is crying. He receives 2 points for his heartbeat because it is over 100. He receives 1 point for acrocyanosis (blue extremities). He receives 2 points for reflexes because he resists the suction catheters. He receives 1 point instead of 2 because his arms are extended instead of flexed. He receives 8 points out of the maximum score of 10 points.

When a woman in early pregnancy is leaving the clinic, she blushes and asks the nurse if it is true that sex during pregnancy is bad for the baby. What is the best response for the nurse to make? 1. "The baby is protected by his sac. Sex is perfectly alright." 2. "It is unlikely to harm the baby. What you do with your personal life is your concern." 3. "In a normal pregnancy, intercourse will not harm the baby. However, many women experience a change in desire. How are you feeling?" 4. "Intercourse during pregnancy is usually alright, but you need to ask the doctor if it is acceptable for you."

3. Intercourse is not harmful during a normal pregnancy. This response recognizes the changes in libido that may occur during pregnancy and allows for the expression of feelings. Answer 1 is factual information, but answer 3 allows the woman to express her feelings. The question says that "she blushes." This may indicate that the woman has concerns about sex. Answer 2 gives factual information but does not allow the woman to express her concerns. Answer 4 again does not give the woman a chance to discuss this with the nurse. The nurse should be able to answer this question.

The nurse is caring for a premature infant. Immediately after arrival in the nursery, which nursing action is essential? 1. Take the rectal temperature 2. Examine for anomalies 3. Check the airway for patency 4. Cleanse the skin of vernix

3. The airway should be checked for patency immediately. Removing vernix is not a high priority. The temperature will be monitored, but this is not the highest priority. The nurse will check for anomalies, but this is not the highest priority. When the infant is stable, he/she will be bathed, and bloody material will be removed. Vernix is good for the skin.

A woman comes to the doctor's office for her routine checkup. She is 34 weeks gestation. The nurse notes all of the following. Which would be of greatest concern to the nurse? 1. Weight gain of 2 lb in two weeks 2. Small amount of dependent edema 3. Fetal heart rate of 155 bpm 4. Blood pressure of 150/94

4. A blood pressure of 150/94 is indicative of pregnancy-induced hypertension. Weight gain of a pound a week, slight dependent edema, and a fetal heartbeat of 155 are all normal.

A woman delivered a baby in the car on the way to the hospital. In the emergency room, the physician examined the mother. What is the priority action for the nurse at this time? 1. Gently tug on the cord and massage the uterus to see if the placenta is ready to be delivered 2. Clamp and cut the cord with sterile scissors 3. Note and record the Apgar score 4. Clear the mucus from the baby's mouth and nose

4. A clear airway for the infant is first priority. Answer 1 is not correct. Tugging on the cord before the placenta is expelled could cause inversion of the uterus. Answer 2 is not correct. The cord does not need to be cut immediately. Clearing the infant's airway is a much higher priority. Answer 3 is not correct. The nurse may assess the infant and get an Apgar score. However, the airway is a much higher priority than the Apgar.

A woman spontaneously delivers a baby girl who is immediately handed to the nurse. Which action is of highest priority for the nurse? 1. Do an Apgar assessment. 2. Check neonatal heart rate. 3. Apply identification bracelets. 4. Clear the nasopharynx.

4. Always make sure the airway is clear first. Apgar scoring is not the licensed practical nurse's responsibility, and it is not the highest priority. Checking heart rate and applying identification bracelets are secondary to clearing the airway.

The nurse is assessing a woman who thinks she may be pregnant. Which information from the client is most significant in confirming the diagnosis of pregnancy? 1. The client is experiencing nausea before bedtime and after meals. 2. The client says she has gained six pounds and her slacks are tight. 3. The client has noticed it is difficult to sleep on her "stomach" because her breasts are tender. 4. The client has a history of regular menstrual periods since age 13, and she has missed her second period.

4. Amenorrhea in an otherwise healthy woman of childbearing age is strongly suggestive of pregnancy. Nausea, weight gain, and tender breasts are all presumptive signs but are not as significant as amenorrhea.

The nurse is preparing a 3-day-old infant for discharge from the hospital. When checking the record for completeness, the nurse checks to see that the infant has had which of the following? 1. DTP and polio immunizations 2. MMR immunization and tuberculin test 3. Pneumococcal vaccine and HIV test 4. Hepatitis B vaccine and PKU test

4. Hepatitis B vaccine is given within the first 12 hours after birth. A PKU test is done when the infant has had milk feedings for 24 hours. DTP and polio immunizations are usually started at two months of age. MMR is given at 15 months. A tuberculin test is usually done at one year. Pneumococcal vaccine is given to infants starting at two months. Newborns are not routinely tested for HIV.

An epidural block is ordered for a woman in labor. Which nursing action is essential because the client has epidural anesthesia? 1. Monitoring the uterus for uterine tetany 2. Giving oxytocin to counteract the effect of the epidural in slowing contractions 3. Having the woman lie flat in bed to avoid postanesthesia headache 4. Monitoring blood pressure for possible hypotension

4. Hypotension is a frequent side effect of regional anesthesia. Maternal hypotension causes fetal bradycardia and hypoxia. Answer 1 is not correct because epidural anesthesia does not cause uterine tetany. Answer 2 is not correct. Even though contractions are sometimes slowed after administering an epidural, oxytocin is not routinely administered. Answer 3 is not correct. The woman who has had an epidural anesthesia will have her head elevated to prevent respiratory depression. Postanesthesia headache occurs after spinal or saddle block anesthesia, not after epidural anesthesia.

A new mother is about to be discharged from the hospital. Which statement made by a new mother indicates a need for more instruction? 1. "I will use my old diaphragm for contraception." 2. "I have an appointment for my six-week checkup." 3. "My mother will be helping me with the children for the next two weeks." 4. "I plan to go back to my job as a secretary in six weeks."

1. A woman should be resized for a diaphragm after the birth of a baby. The old one may no longer be the correct size. The resizing will occur after involution is completed, usually at her six-week checkup. If sexual activity is resumed before that time, another means of contraception (such as the condom) should be used if she does not wish to get pregnant. All of the other responses indicate understanding of postpartum care.

The nurse is caring for a woman who is 30 weeks gestation, has gained 17 pounds during the pregnancy, and has a blood pressure of 110/70. The woman states that she feels warmer than everyone around her. Which interpretation of these findings is most correct? 1. All of these findings are normal. 2. Her weight gain is excessive for this point in pregnancy. 3. The blood pressure is abnormal. 4. She should be evaluated for a serious infection because pregnant women are usually cooler than other people.

1. All of these findings are within normal limits. Weight gain during the first trimester is usually 3 to 5 lb. After that, the normal weight gain is around 12 oz (three-quarters of a pound) a week. Using these guidelines, her weight gain should be 16 to 18 lb. Her blood pressure is well within normal limits, even though we are not given a baseline. Pregnant women have a high metabolic rate and usually feel warmer than everyone else.

The nurse is caring for a woman who had a postpartum hemorrhage. Which of the following facts about her delivery most likely contributed to her hemorrhage? 1. The baby weighed 10 lb 6 oz. 2. She received Pitocin after delivery of the placenta. 3. She delivered 10 days after her due date. 4. Her second stage of labor lasted an hour.

1. An overstretched uterus is subject to hemorrhage. A large baby causes additional stretching of the uterus. Answer 2 is not correct. Pitocin contracts the uterus and decreases hemorrhage. It is also standard procedure following delivery. Answer 3 is not correct. Delivering after the due date itself does not increase postpartum hemorrhage. However, the large baby does. Answer 4 is not correct. It is normal for the second stage of labor to last an hour.

A 23-year-old woman, pregnant for the first time, is 39 weeks gestation. She is admitted to the labor room with contractions every five minutes lasting 45 seconds. On vaginal exam, she is noted to be completely effaced and 5-cm dilated. Station is 0. She asks the nurse for pain medication. What is the best response for the nurse to make? 1. "I'll ask your doctor for medication." 2. "Can you hold out for a few more minutes? It's too soon for you to have medication." 3. "Pain medication will hurt your baby. We would rather not give you any unless absolutely necessary." 4. "Can your husband help you with your breathing techniques?"

1. Analgesia can usually be safely given after 5 cm of dilation and until one to two hours before delivery. Answer 2 is not appropriate because according to the data given, the mother is a good candidate for some type of analgesia. Answer 3 is not true. Pain medication too early may slow labor, and pain medication too late may depress the baby's respirations and heartbeat. Pain medication given appropriately is often very helpful during labor. Answer 4 is not appropriate. It does not address the question that the client asked about pain medication.

A woman who had a cesarean section tells the nurse, "I guess I flunked natural childbirth because I had to have a cesarean." This statement is most indicative of which phase of postpartum adjustment? 1. Taking in 2. Working through 3. Taking hold 4. Letting go

1. By discussing her experience, she is bringing it into reality. This is characteristic of the taking in phase. The taking hold phase is when the mother tries to reassert her control of the family, and letting go is when the baby is integrated into the family. Working through is not one of the phases of postpartum adjustment.

A woman in labor does not continue to dilate. The physician decides to perform a cesarean section. A healthy 7-lb, 12-oz baby boy is delivered. What is the most essential nursing intervention in the immediate postpartum period? 1. Check the uterine fundus for firmness. 2. Assess the episiotomy for bleeding. 3. Assist the woman with accepting the necessity of having had a cesarean section. 4. Encourage fluid intake.

1. Checking the uterine fundus for hemorrhage is of highest priority. The placenta separates from the uterus in a woman who has had a cesarean delivery just as it does in a vaginal delivery. Both types of deliveries have a risk of postpartum hemorrhage. It is essential to keep the fundus firm for both types of deliveries. The woman who had a cesarean delivery has no episiotomy. Assisting with emotional adjustment will be a part of nursing care but is not the highest priority. Encouraging fluid intake is important but is not the highest priority.

Parents of a newborn note petechiae on the newborn's face and neck. The nurse should tell them that this is a result of which of the following? 1. Increased intravascular pressure during delivery 2. Decreased vitamin K level in the newborn infant 3. A rash called erythema toxicum 4. Excessive superficial capillaries

1. Increased intravascular pressure during delivery can cause petechiae. These will quickly disappear. Decreased vitamin K level in the infant might predispose the infant to bleeding from the umbilical cord but does not cause petechiae on the face and neck. Erythema toxicum is a generalized rash sometimes seen in newborns. It is not limited to the face and neck. Petechiae are not a result of excessive superficial capillaries.

A woman who is completely dilated is pushing with contractions. After 30 minutes of pushing, the baby is still at 0 station. What is the most appropriate nursing action at this time? 1. Assess for a full bladder 2. Prepare for a cesarean delivery 3. Monitor fetal heart tones 4. Turn the mother to her left side

1. Lack of descent is often related to a full bladder. Answer 2 is not correct. Until a full bladder has been ruled out as a cause of failure to descend, cesarean delivery would not be considered. Answer 3 is not correct. Routine fetal assessment will of course be done. However, there are no specific data suggesting a fetal problem and no need for additional fetal monitoring. Answer 4 is not correct. Position is not the most likely cause for failure to descend. Turning the mother to the left side would be an appropriate intervention for a sudden drop in blood pressure resulting from vena caval syndrome.

Magnesium sulfate is ordered for a client who is hospitalized for pregnancy-induced hypertension (PIH). What effects would the nurse expect to see as a result of this medication? 1. CNS depression 2. Decreased gastric acidity 3. Onset of contractions 4. Decrease in number of bowel movements

1. Magnesium sulfate is a central nervous system depressant. It is given to prevent seizures. Magnesium hydroxide gel is an antacid. Oxytocin is given to initiate contractions. Magnesium sulfate may decrease contractions. Magnesium sulfate does not cause constipation. Some laxatives contain magnesium.

On the evening of the second day after birth, the nurse notes that an infant appears icteric. What is the most likely cause? 1. Rupture of a great number of fragile red cells in a short period of time 2. Inflammatory obstruction of hepatic bile ducts and resorption of pigments 3. Extravasation of blood from ruptured capillaries into subcutaneous tissue 4. Faulty melanin metabolism due to absence of enzymes for normal protein synthesis

1. Red blood cells of premature infants are fragile and break down rapidly, causing an increase in bilirubin, which causes icterus or jaundice. The timing is key. Jaundice occurring after 49 hours is usually physiological jaundice. Jaundice presenting at birth or within the first 24 hours is usually pathological in nature. Obstruction of hepatic bile ducts would be a pathological cause of jaundice and would occur earlier. Answer 3 is not realistic. This might cause a bruising appearance but not jaundice. Answer 4 makes no sense.

A new mother has decided not to breastfeed her baby. Which statement indicates the best understanding of the management of engorgement? 1. "I will stand with my back to the shower." 2. "I will take a sitz bath every day." 3. "I will apply a warm compress to my breasts three times a day." 4. "I will drink a lot of liquids for the next few days."

1. Standing with her back to the shower will keep the warm water from stimulating milk production. Cool compresses will help with engorgement; warm compresses stimulate milk flow. A sitz bath is indicated for an episiotomy. It is not related to the care of the breasts. Consumption of excess fluids will encourage milk production. Some additional fluids are necessary during the diaphoresis/diuresis phase after delivery.

A woman is admitted to the postpartum unit two hours after delivery of a baby. What action is especially important because the membranes were ruptured for 28 hours before delivery? 1. Monitor her temperature every two hours 2. Provide perineal care with Zephiran every four hours 3. Maintain a strict perineal pad count 4. Have the mother take a sitz bath four times a day

1. Temperature over 100.4°F after the second day usually indicates infection. Infection is the most frequent maternal complication after prolonged rupture of the membranes. Zephiran perineal care is not a current practice and is not related to prolonged rupture of the membranes. A strict perineal pad count is not necessary. Sitz baths are a comfort measure for a sore perineum and are not related to prolonged rupture of the membranes.

A woman who is 28 weeks gestation comes to the emergency room with painless, bright red bleeding of 1.5 hours in duration. Which of the following would the nurse expect during assessment of this woman? 1. Alterations in fetal heart rate 2. Board-like uterus 3. Severe abdominal pain 4. Elevated temperature

1. The history suggests placenta previa. The baby may well develop fetal distress. A boardlike abdomen and severe pain are characteristic of abruptio placenta. Elevated temperature is not characteristic of placenta previa.

A woman who had a normal vaginal delivery two hours ago has just arrived on the postpartum floor. Vital signs are normal. When assessing her uterus, the nurse notes that it is boggy. What should be the nurse's initial intervention? 1. Massage the uterus 2. Report to the charge nurse 3. Contact the doctor stat 4. Continue to assess it frequently

1. The initial response is to massage the uterus. Most of the time, massaging the uterus will cause it to firm up immediately. If it does not respond to massage by becoming firm, then the practical nurse should report it to the charge nurse or contact the physician. The nurse will continue to assess frequently after massaging the fundus. Note that the question asked for the initial intervention.

The nurse is caring for a woman who delivered a baby three hours ago. The woman pulls the emergency call light and says she is bleeding all over the bed. The nurse enters the room and sees the blood-soaked bed. What is the best initial action for the nurse to take? 1. Assess and massage the fundus if soft 2. Take vital signs 3. Place the client in sharp Trendelenburg position 4. Notify the physician immediately

1. The most common cause of postpartum hemorrhage is uterine atony. Always assess the fundus first and massage it if it is not firm. Taking vital signs and notifying the physician will be done after the nurse assesses and massages the fundus if necessary. The client will not be placed in the Trendelenburg position.

A young woman delivered her first baby this morning. She asks the nurse why the top of the baby's head is so soft and does not seem to have any bone. What should the nurse include when responding to the mother? 1. This soft spot is called a fontanel and is normal; it makes delivery easier. 2. It is a condition that occurs in some babies and will disappear within a few days. 3. The physician is monitoring the infant for any problems that might occur with this common defect. 4. It is called caput succedaneum and is caused by bleeding under the scalp during birth.

1. The mother appears to be describing the anterior fontanel, or soft spot, which occurs in all babies. The skull bones are not completely fused, allowing molding of the head during the birth process. This should close between 12 and 18 months. It is a normal condition occurring in all babies and is not a defect. Caput succedaneum is a swelling that may occur on the head following delivery. It crosses suture lines and is due to swelling under the scalp during birth. It is normal and disappears in a few days. This is not what is described in the question.

A newborn has a total body response to noise or movement that is distressing to her parents. What should the nurse tell the parents about this response? 1. It is a reflexive response that indicates normal development. 2. It is a voluntary response that indicates insecurity in a new environment. 3. It is an automatic response that may indicate that the baby is hungry. 4. It is an involuntary response that will remain for the first year of life.

1. The response described is the startle reflex and is normal in newborns. It lasts only a few months.

The mother of a newborn is breastfeeding her infant on the delivery table. How can the nurse best assist her? 1. Touch the infant's cheek adjacent to the nipple to elicit the rooting reflex 2. Leave the mother and baby alone and allow the infant to nurse as long as desired 3. Position the infant to grasp the nipple so as to express milk 4. Give the infant a bottle first to evaluate the baby's ability to suck

1. The rooting reflex is stimulated when the cheek next to the breast is gently stroked. Answer 2 is not correct. The nurse should not leave the mother and baby alone until the nurse is confident that mother and baby are doing well. The infant should not nurse long enough to cause sore nipples. Answer 3 is not correct. The infant should grasp the areola, not the nipple. Answer 4 is not correct. Giving a bottle first would serve no purpose and might interfere with nursing.

Which nursing action has the highest priority for a client in the second stage of labor? 1. Help the mother push effectively 2. Prepare the mother to breastfeed on the delivery table 3. Check the fetal position 4. Administer medication for pain

1. The second stage of labor is the pushing stage. The nurse should help the mother push effectively. Answer 2 is not correct. The mother cannot breastfeed the infant until it is born. Breastfeeding on the delivery table might be an appropriate action in the third stage of labor. Answer 3 is not correct. Checking the fetal position is not the highest priority action during second stage labor. Answer 4 is not correct. Pain medication should not be administered in the second stage because it will cause a sleepy baby.

A new mother is in the first period of adjustment following birth called the taking-in phase. What type of maternal behavior would the nurse expect her to exhibit? 1. Passivity and dependence 2. Preoccupation with baby's needs 3. Independence 4. Resuming control of life

1. The taking in period is characterized by passivity and dependence. The mother relives her labor and integrates it into her being. Preoccupation with the baby's needs and reasserting independence are characteristic of the taking hold phase, which follows the taking in phase. Resuming control of life is characteristic of the letting go phase.

A 21-year-old married woman thinks she may be pregnant. She goes to her physician and tells the nurse that the drugstore test was positive for pregnancy. She asks the nurse if the test is reliable. What is the best response for the nurse to make? 1. "The tests are quite reliable. In order to be sure you are pregnant, I need to get some more information from you." 2. "The tests are less reliable than the one the doctor does. We will have to repeat it." 3. "Those kits are not very reliable. Your doctor should make the diagnosis." 4. "They are very reliable. You can be sure you are pregnant."

1. The tests are quite reliable. They are based on the presence of hCG (human chorionic gonadotropin), which is secreted during pregnancy. Physician tests use the same principle. The nurse should take a history to confirm the results of the tests. The physician will examine the woman to help confirm the test results.

The nurse is caring for a laboring woman who has a history of rheumatic heart disease. Which instruction should the nurse give to her during the second stage of labor? 1. Avoid prolonged bearing down. 2. Breathe shallowly and rapidly. 3. Sit on the side of the bed. 4. Sleep between contractions.

1. The woman with cardiac disease should not bear down excessively. She will likely be given an epidural anesthesia, and outlet forceps may be indicated to shorten the second stage of labor. Answer 2 is not correct. Breathing shallowly and rapidly will cause respiratory alkalosis. Answer 3 is not correct. Sitting on the side of the bed is not an appropriate action during second stage labor. Second stage labor is the expulsion stage. Answer 4 is not correct. Sometimes mothers do doze between contractions in second stage. However, answer 1 is the priority instruction that the nurse should give this mother.

A laboring woman is to be transferred to the delivery room. The nurse is positioning her on the table when she has a very strong contraction and starts to bear down. What should the nurse tell her to do? 1. Pant 2. Bear down strongly 3. Put her legs up in the stirrups 4. Ignore the contraction

1. When it is not desirable for a woman to push, such as when moving from bed to table, she should be instructed to pant. It is not possible for a woman to pant and push at the same time. The mother will probably be unable to put her legs up in stirrups during a contraction. At this stage of labor, she will be unable to ignore contractions.

A woman who is 32 weeks gestation is admitted with contractions every four minutes. Ritodrine is given for which of the following purposes? 1. To suppress uterine activity 2. To make her more comfortable 3. To enhance contractions 4. To increase fetal oxygenation

1.This woman is in premature labor. Ritodrine is used to suppress uterine activity. Note that answers 1 and 3 are opposites. Usually when there are opposites, one of the opposites is the correct answer. It would not be logical to enhance contractions in a woman who is not at term. Ritodrine is not an analgesic and does not increase fetal oxygenation.

Which of the following is the most important nursing assessment during the fourth stage of labor? 1. Bonding behaviors 2. Distention of the bladder 3. Ability to relax 4. Knowledge of newborn behavior

2. A distended bladder may interfere with involution of the uterus and cause excessive bleeding. The nurse will observe for appropriate bonding behaviors and maternal relaxation and maternal knowledge of newborn behavior, but the most important is assessment for bladder distention (because that could cause uterine relaxation and hemorrhage).

The nurse is caring for a woman who had a normal vaginal delivery two hours ago and has just arrived on the postpartum floor. Two hours later, her uterus is displaced to the right. What is the most likely explanation for this? 1. A fibroid tumor 2. A full bladder 3. An increase in interstitial fluid 4. Retained placental fragments

2. A full bladder causes the uterus to be elevated above the umbilicus and displaced to the right. A fibroid tumor, if present, would not cause a change in position of the uterus in a two- hour time period. Interstitial fluid does not accumulate in the uterus and could not cause the uterine position change. Retained placental fragments would cause an increase in vaginal bleeding or a boggy fundus but not displacement of the fundus.

A woman, at 32 weeks gestation, delivers a 3-lb, 8-oz baby boy two hours after arriving at the hospital. What is the baby at risk for because of his gestational age? 1. Mental retardation and seizures 2. Hypothermia and respiratory distress 3. Acrocyanosis and decreased lanugo 4. Patent ductus arteriosus and pneumonia

2. A premature infant lacks fat cells and is not able to alter body temperature. He has decreased surfactant and is apt to develop respiratory distress. Mental retardation and seizures are possible later complications of prematurity. Acrocyanosis is normal. Decreased lanugo is seen at term; a premature infant has more lanugo. Patent ductus arteriosus is not specifically related to prematurity. Pneumonia is not specifically related to prematurity.

The nursing care plan for a woman who has placenta abruptio should include careful assessment for signs and symptoms of which of the following? 1. Jaundice 2. Hypovolemic shock 3. Impending convulsions 4. Hypertension

2. Abruptio placenta causes hemorrhage, either apparent or concealed. The nurse must observe for hypovolemic shock. Jaundice is not seen with placenta abruptio. Convulsions occur with eclampsia or pregnancy-induced hypertension. The client who is hemorrhaging will develop shock, not hypertension. Note the opposites; shock is low blood pressure, and hypertension is high blood pressure. The answer is likely to be one of the opposites.

The mother of a term newborn born two hours ago asks the nurse why the baby's hands and feet are blue. What information should the nurse include when responding? 1. Blue hands and feet can indicate possible heart defects. 2. This is normal in newborns for the first 24 hours. 3. This pattern of coloration is more common in infants who will eventually have darker skin color. 4. Once the baby's temperature is stabilized, the hands and feet will warm up and be less blue.

2. Acrocyanosis or blue hands and feet is normal for the first 24 hours of life and is thought to be related to the establishment of circulation after delivery. Acrocyanosis in the first 24 hours does not suggest heart defects. Continuing acrocyanosis might. Bluish discolorations over the lower back and buttocks are called Mongolian spots and are typical in infants with more pigment in their skin. Acrocyanosis is not related to the regulation of temperature as much as it is related to the establishment of nonfetal circulatory patterns.

After several hours of active labor, a woman says to the nurse, "I have to push. I have to push." What is the best initial response for the nurse to make? 1. "Pull your knees up to your chest and hold on to them. Take a deep breath and push down as though you are having a bowel movement." 2. "Let me have the RN examine you before you start to push." 3. "That means the baby is coming. I'll take you into the delivery room now." 4. "Women often feel that way during labor. Turn on your left side, and you will be more comfortable."

2. Before encouraging the mother to push, the nurse should determine that the mother has completed transition and is fully dilated. She should not push before she is fully dilated. Answer 1 is a good description of pushing. However, the woman should not push until she is fully dilated. Most women need to push for a while before the baby is born. Answer 4 is a true statement; however, it is not the best response for the nurse to make.

Six hours after delivery, the nurse notes that a woman's fundus is two finger breadths above the umbilicus and deviated to the right of the midline. What is the most likely cause of this finding? 1. Retained placental fragments 2. Bladder distention 3. Normal involution 4. Second-degree uterine atony

2. Bladder distention causes uterine displacement, which interferes with involution and may lead to postpartum hemorrhage. With normal involution, the fundus would be at or slightly above the umbilicus and in the midline. Retained placental fragments and uterine atony would cause excessive bleeding.

The nurse asks the newly pregnant woman if she has a cat for which of the following reasons? 1. Cats may suffocate new babies and should not be in the home when a baby arrives. 2. Cat feces may cause toxoplasmosis, which can lead to blindness, brain defects, and stillbirth. 3. If the mother gets scratched by a cat, the baby may develop heart defects. 4. Cats are jealous of babies and may try to kill them during infancy.

2. Cats may become infected with toxoplasmosis, which, if ingested by the mother, can cause toxoplasmosis and lead to neurologic lesions causing blindness, brain defects, and death. Parents should be alert for safety with any pet, but cats do not suffocate new babies or try to kill them. It is not being scratched by a cat that is the biggest danger during pregnancy; it is the possibility of developing toxoplasmosis from the feces. Raw meat can also carry toxoplasmosis.

Awomaninlaborisexperiencingverystrong contractions every two to three minutes, lasting 60 to 75 seconds. She complains of a severe backache and is irritable. The best interpretation of these data is that the woman is in which stage/phase of labor? 1. Early first stage of labor 2. Transition phase of labor 3. Late second stage of labor 4. Early third stage of labor

2. Contractions during the transition phase typically occur every two to three minutes and last 60 to 90 seconds. The woman is often irritable and has a backache. Answer 1 is not correct. Early first stage labor contractions are usually several minutes apart, lasting only a few seconds. Backache and irritability are not common in early first stage labor. Answer 3 is not correct. Late second stage labor is the "pushing stage" just before delivery. Early third stage labor is after delivery of the baby, just before the placenta is expelled. Third stage labor is usually only a few minutes.

On the first day after a cesarean section, the client is ambulating. She is uncomfortable and asks the nurse, "Why am I being made to walk so soon after surgery?" What is the nurse's best response? 1. "You can get to hold your baby more quickly if you walk around." 2. "Early walking keeps the blood from pooling in your legs and prevents blood clots." 3. "Walking early will prevent your wound from opening." 4. "Early walking helps lower the incidence of wound infection."

2. Early walking helps to prevent thrombophlebitis. She does not have to walk in order to hold her baby. Walking does not prevent dehiscence or wound infection.

A woman who is in early pregnancy asks the nurse what to do about her "morning sickness." What should the nurse include in the reply? 1. Eating a heavy bedtime snack containing fat helps to keep nausea from developing in the morning. 2. Eating dry crackers before getting out of bed may help. 3. Drinking liquids before getting up in the morning helps relieve nausea. 4. The doctor can prescribe an antiemetic if she has had three or more vomiting episodes.

2. Eating dry carbohydrates in the morning before rising often helps. The woman should avoid fatty foods and those with strong odors. Drinking liquids in the morning usually makes morning sickness worse, not better. Antiemetics are not prescribed because of the possible teratogenic effect on the developing embryo.

What should the nurse do to assess for a positive sign of pregnancy? 1. Perform a pregnancy test on the woman's urine. 2. Auscultate for fetal heart sounds. 3. Ask the woman when she had her last menstrual period. 4. Ask the woman if her breasts are tender.

2. Fetal heart sounds, sonograms, and x-rays are positive signs of pregnancy. A positive pregnancy test is a probable sign of pregnancy. Amenorrhea and breast tenderness are presumptive signs of pregnancy.

A pregnant woman comes for her sixth-month checkup and mentions to the nurse that she is gaining so much weight that even her shoes and rings are getting tight. What should the nurse plan to include in her care? 1. Teaching about the food pyramid and the importance of a well-balanced diet 2. Further assessment of her weight, blood pressure, and urine 3. Encouraging the use of a comfortable walking shoe with a medium heel 4. Reassurance that weight gain is normal as long as it does not exceed 25 lb

2. Her symptoms suggest pregnancy-induced hypertension; particularly significant is the fact that her rings are getting tight. Upper body edema is highly suggestive of PIH. The nurse should record her weight and note how much weight has been gained in the last month. Monitoring blood pressure for elevation and checking urine for protein will help to determine if this woman has PIH. Dietary teaching as described in answer 1 is important, but the action relating to the data in the question is assessment for PIH. The advice in answer 3 regarding a comfortable walking shoe is also appropriate for a pregnant woman but does not relate to the data in this question. More important than total weight gain is the pattern of weight gain. A sudden increase in weight gain may indicate fluid retention accompanying PIH, even if the total is not yet 25 or 30 lb.

The physician has told the parents that their child probably has phenylketonuria. The parents ask the nurse what special needs the child will have. What should the nurse include in the response? 1. The baby will most likely not develop normally for longer than six months and will die in a few years. 2. The baby will have a special formula and cannot eat protein foods during childhood. 3. Special feeding techniques are necessary until the child has surgery. 4. The baby will not be able to void normally and will need to be catheterized frequently.

2. Phenylketonuria is a disorder of purine metabolism in which phenylalanine is not metabolized properly and builds up in the blood and brain and causes severe mental retardation if not treated promptly. The treatment is to avoid foods containing phenylalanine. The child will have a special formula (Lofenalac) and cannot eat protein-containing foods. If diagnosed early and if the proper diet is followed, the child should do well. Answer 1 is more typical of Tay-Sachs disease. Answer 3 is typical of cleft lip or palate.

A 40-year-old woman who is 28 weeks gestation comes to the emergency room with painless, bright red bleeding of 1.5 hours duration. What condition does the nurse suspect this client has? 1. Abruptio placenta 2. Placenta previa 3. Hydatidiform mole 4. Prolapsed cord

2. Placenta previa is characterized by painless bleeding in the third trimester. Abruptio is characterized by abdominal pain and a rigid abdomen with or without obvious bleeding. Shock develops rapidly in placenta abruptio. Hydatidiform mole is characterized by severe nausea and vomiting and the passage of grapelike vesicles. Prolapsed cord often occurs when the membranes rupture and is not characterized by bleeding.

A client with PIH asks the nurse, "When will I get over this?" What is the best response for the nurse to make? 1. "Your disease can be controlled with medication." 2. "After your baby is born." 3. "After delivery, you will need further testing." 4. "You could have this condition for years."

2. Preeclampsia is pregnancy-induced hypertension and disappears shortly after the birth of the baby.

The nurse is positioning a laboring woman who has not reached the transition phase. The nurse should avoid placing her in the supine position because the supine position has which effect? 1. It increases gravitational forces and prolongs labor. 2. It causes decreased perfusion of the placenta. 3. It may impede free movement of the symphysis pubis. 4. It frequently leads to transient episodes of hypertension.

2. Pressure of the uterus against major blood vessels reduces circulation, causing decreased perfusion of the placenta. Answer 1 is not correct; the supine position does not prolong labor. Answer 3 is not correct; the supine position does not impede free movement of the symphysis pubis. Answer 4 is not correct; the supine position does not cause transient episodes of hypertension in the laboring woman.

The delivery room nurse is explaining Apgar scoring to new parents. Which information pertaining to the purpose of a five-minute Apgar score should be included in the explanation? 1. It evaluates the effectiveness of the labor and delivery. 2. It measures the adequacy of transition to extrauterine life. 3. It assesses the possibility of respiratory distress syndrome. 4. It gives an estimate of the gestational age of the infant.

2. The Apgar score assesses the infant on respiratory effort, heart rate, color, reflexes, and muscle tone. These indicate his adaptation to extrauterine life. The purpose of the Apgar score is not to evaluate the effectiveness of labor and delivery, assess respiratory distress syndrome, or give an estimate of gestational age of the infant.

The day after delivery, a new mother asks why her milk is so creamy and yellow. What is the best response for the nurse to make? 1. "I wouldn't worry about it." 2. "This is normal. It will soon turn to real milk." 3. "You're coming along fine." 4. "You haven't gotten your milk in yet."

2. The client is describing colostrum. Milk comes in about 72 hours after delivery. Answers 1 and 3 do not address the question asked by the mother. Answer 4 is technically accurate but does not give as much information and reassurance as answer 2.

The nurse is teaching a prenatal class. A woman in the class who is eight months pregnant asks why her feet swell. The nurse includes which of the following information in the answer? 1. Swollen feet during pregnancy can indicate a serious problem. 2. The enlarging baby reduces venous return, causing retention of fluid in the feet and ankles. 3. Swelling of the feet during pregnancy is usually related to PIH. 4. Swelling of the feet during pregnancy is due to the increased blood volume and will disappear after delivery.

2. The enlarging fetus presses on the veins returning fluid from the lower extremities, causing fluid retention. Swelling of the upper extremities or face may indicate pregnancy-induced hypertension. There is an increased blood volume during pregnancy, but this does not by itself cause swelling in the lower extremities.

A woman who is at about six weeks gestation asks if she can listen to the baby's heartbeat today. What should be included in the nurse's reply? 1. The heart is not beating at six weeks. 2. The heart is formed and beating but is too weak to be heard with a stethoscope. 3. The heartbeat can be heard with an electronic fetoscope. 4. The heart does not start beating until 20 weeks gestation.

2. The heart chambers are formed and the heart is beating by four weeks gestation. However, it cannot be heard even with a fetoscope. Answer 1 is incorrect. The heart is beating by four weeks. Answer 3 is not correct. It cannot be heard at this time. Answer 4 is incorrect. The heart rate will be audible with a standard fetoscope by 20 weeks, but it has been beating since about four weeks.

A woman, gravida 5, para 4, is unable to get to the hospital because labor has progressed very rapidly. A nurse, who lives upstairs, comes down to assist her with the emergency home delivery. The nurse examines the woman and assesses that the perineum is bulging. What is the priority nursing measure at this time? 1. Encourage the woman to push during the contraction 2. Place a clean sheet under the perineal area 3. Accurately time the contractions 4. Contact the physician by phone for instructions

2. The woman is a gravida 5, para 4, and the perineum is bulging. Delivery is imminent. Contamination will be minimized by catching the infant on a clean surface. Answer 1 is not correct. The woman will not need to be encouraged to push; she will be doing it on her own. Secondly, it will be more appropriate to have her pant so that the delivery can be controlled. Answer 3 is not correct. Delivery is imminent. There is no time or need to time the contractions. Answer 4 is not correct. Delivery is imminent. There is no time to contact the physician for instructions. The nurse should be able to handle this emergency delivery.

The doctor told a pregnant woman to eat a well- balanced diet and increase her iron intake. She says, "I hate liver. How can I increase my iron?" What is the best response for the nurse to make? 1. "Although liver is a good source of iron, beets, poultry, and milk are also good sources." 2. "Many people dislike liver. Red meats, dark green vegetables, and dried fruits are also good sources of iron." 3. "You should eat liver as it is the best source of iron. There are lots of ways to disguise the taste." 4. "You can eat almost anything you like because your prenatal vitamins have all the vitamins and minerals needed for a healthy pregnancy."

2. This answer recognizes that a dislike of liver is common and suggests good sources of iron. Answer 1 includes information that is not correct; milk contains no iron. Answer 3 has some correct information; liver is high in iron. It is also high in cholesterol. There are many other sources of iron. It is not necessary to eat liver to get iron in the diet. At one time, eating liver regularly was thought to be the best way to get iron. Answers 3 and 4 are not the best answers. Prenatal vitamins do contain iron. However, they should not be considered a substitute for a proper diet.

Methergine 5 mg qid is ordered for a postpartum client. An hour after taking the drug, the woman complains of uterine cramping. What is the best explanation for the nurse to give her? 1. "This is an unfortunate side effect, but you need the medicine." 2. "The cramping is uncomfortable, but it is a sign that the drug is keeping your uterus contracted so you won't bleed too much." 3. "Since you are experiencing cramps, I'll ask the doctor to discontinue the drug." 4. "The cramping should decrease soon. If it does not, let me know. I'll see if the doctor will decrease the dosage."

2. This response explains the drug's action to the client. Methergine is an oxytocic drug that helps the uterus to contract and prevents postpartum bleeding. Answer 1 is not correct because it does not give the mother the information she needs to understand why she is cramping. Answers 3 and 4 are not accurate.

After her examination by the physician, the antepartal client tells the nurse that the doctor said she had positive Chadwick's and Goodell's signs. She asks the nurse what this means. What is the best response for the nurse to make? 1. "Chadwick's sign is a dark blue coloring of the vagina and cervix. Goodell's sign is softening of the cervix of the uterus." 2. "These help to confirm pregnancy. They refer to color changes and changes in the uterus caused by increased hormones of pregnancy." 3. "Those are medical terms. You don't need to be concerned about them." 4. "It refers to changes that occasionally happen in pregnancy but are unlikely to cause problems."

2.This answer is most appropriate to give the client. Answer 1 is a true statement but uses vocabulary that is inappropriate for the client. These changes are normal changes and occur in most pregnancies. Answer 3 is a real put-down to the client. Answer 4 is not correct. These are normal findings that help to confirm the diagnosis of pregnancy.

The physician is performing an amniotomy on a woman in labor. What is the most important nursing action during this procedure? 1. Assist the physician 2. Keep the mother informed 3. Monitor fetal heart tones 4. Encourage slow chest breathing

3. Amniotomy can be stressful for the fetus. Assessing the fetal heart rate is the priority nursing measure during amniotomy. Keeping the mother informed is not as important as fetal safety. The procedure is painless, so breathing techniques are not necessary.

A woman who is giving birth at home wonders if her baby will need drops in the eyes because she knows that neither she nor her husband has gonorrhea. The best answer for the nurse to give should include which of the following? 1. It is desirable for the baby to receive the eye drops, but it is not essential. 2. If you do not want your baby to have the eye drops, you must sign a waiver stating that you refuse them. 3. The baby needs the drops but does not have to receive them for up to two hours after birth. 4. The drops are needed to prevent the eye condition known as retrolental fibroplasia.

3. Antibiotic eyedrops have to be instilled in to the neonate's conjunctival sacs to prevent infection, not just from gonorrhea and chlamydia but also from pathogens in the birth canal such as pneumococcus and Streptococcus. It is safe to wait up to two hours to instill the drops. This allows time for maternal-child eye contact and interaction, which facilitates attachment. Answers 1 and 2 are not correct. There is a legal requirement to give the baby eye prophylaxis. Answer 4 is not correct. Retrolental fibroplasia results from too much oxygen concentration in immature retinal vessels during oxygen therapy for the compromised neonate.

During an emergency home delivery, the head is beginning to crown. What is the most appropriate action for the nurse to take at this time? 1. Instruct the mother to push down vigorously. 2. Press down on the fundus to expel the baby. 3. Apply gentle perineal pressure to prevent rapid expulsion of the head. 4. Direct the mother to take prolonged deep breaths to improve fetal oxygenation.

3. Applying gentle counter pressure to the perineum prevents too rapid expulsion of the head, which can lead to increased intracranial pressure in the infant and laceration in the mother. Answer 1 is not correct. The mother will be encouraged to pant so that the delivery can be controlled. Answer 2 is not correct. The nurse does not press down on the fundus to expel the baby. Answer 4 is not correct. There is no need to tell the mother to take prolonged deep breaths. Applying gentle perineal pressure is by far the most appropriate action for the nurse at this time.

A woman who delivered today by cesarean delivery asks the nurse, "How come my baby has such a round head? My other baby's head was not so round, and she was more red." What is the best response for the nurse to make? 1. "Each baby is different. It is not a good idea to compare your children." 2. "Were forceps used when your older child was delivered?" 3. "Babies born by cesarean have rounder heads because they do not go through the birth canal." 4. "A round head is a sign the baby is very intelligent. Your child should do very well in school."

3. Babies born by cesarean delivery do not have molded heads because they have not passed through the pelvis and the birth canal. The other responses are not helpful. Answer 1 does not address the question. Forceps can cause distinctive marks on the head. A round head is not a sign of intelligence.

Orders for a premature infant are for nipple feedings or gavage. What assessment findings are necessary before nipple feedings are given? 1. The baby must have a respiratory rate of 20 to 30 and heart rate of 110 to 130. 2. The baby must be alert and rooting. 3. Sucking and gag reflexes must be present. 4. Weight and temperature must be stable.

3. Before an infant can be given nipple feedings, he/she must have sucking and gag reflexes to prevent aspiration. The respiratory rate and heart rate given in answer 1 are below those of term infants and are totally unrealistic. A baby who is alert and rooting but does not have sucking and gag reflexes should not be given nipple feedings. Stable weight and temperature are not requirements for nipple feeding.

What action is essential for the nurse during the fourth stage of labor? 1. Firmly massage the fundus every 15 minutes. 2. Take the vital signs every 1 hour. 3. Turn the client on her side during a lochia check. 4. Assist the client to the bathroom to void.

3. Lochia can accumulate under the buttocks. It cannot be accurately observed in a supine position. The nurse assesses the fundus every 15 minutes and massages it only when it is soft. Vital signs will be every 15 minutes, not every hour. The client will not get up to void this soon after delivery.

When changing her newborn infant, a mother notices a reddened area on the infant's buttocks. How should the nurse respond? 1. Have staff nurses instead of the mother change the infant 2. Use both lotion and powder to protect the area 3. Encourage the mother to cleanse and change the infant more frequently 4. Notify the physician and request an order for a topical ointment.

3. More frequent changing and cleaning of the area should help to prevent diaper rash. The mother should learn how to care for her baby and should be encouraged to change the infant. Using both lotion and powder would create a caked mess. The description in the question suggests a diaper rash. There is no need to contact the physician. The nurse will, of course, record the observation on the client's record.

The nurse has just completed emergency delivery of a term infant. What is the priority nursing concern at this time? 1. Controlling hemorrhage in the mother 2. Removing the afterbirth 3. Keeping the infant warm 4. Cutting the umbilical cord

3. Newborns have immature temperature regulating mechanisms. The nurse should dry the infant and place the infant in a blanket or towel on the mother's abdomen. Answer 1 is not correct. The first concern is clearing the infant's airway and keeping the infant warm. The mother is not likely to hemorrhage at this time. Maternal hemorrhage would be more likely after delivery of the placenta. Answer 2 is not correct. The afterbirth or placenta should separate and deliver itself within 5 to 15 minutes after the baby is born. The nurse should care for the baby until this happens. Answer 4 is not correct. There is no hurry to cut the cord. The cord should never be cut with anything that is not sterile because the baby could develop a fatal infection.

In establishing a teaching plan for a client who is in the first trimester of pregnancy, the nurse identifies a long list of topics to discuss. Which is most appropriate for the first visit? 1. Preparation for labor and delivery 2. Asking the woman what questions and concerns she has about parenting 3. Nutrition and activity during pregnancy 4. Dealing with heartburn and abdominal discomfort

3. Nutrition and activity are important concerns from the first trimester onward. Labor and delivery is a third trimester concern, and parenting is of most concern in either the third trimester or after delivery. Heartburn and abdominal discomfort do not usually occur until the third trimester.

A woman is in labor with her first baby. She has prepared for a natural childbirth. As labor progresses, she becomes increasingly irritable with her husband, complaining of lower back pain and fatigue. What is the most appropriate response for the nurse to make? 1. Have the client turn on her side and give her a back rub. 2. Ask the client if she would like the doctor to give her something for the discomfort. 3. Reassure the husband that irritability is normal now, and teach him to apply pressure to his wife's lower back. 4. Encourage the client to try and get some rest, and ask her husband if he would like to take a coffee break.

3. Rubbing the lower back usually helps the husband deal with his feelings of helplessness and fosters the couple's sense of mutual experience. Answer 1 is not appropriate because it is better for the mate to give the back rub if he is able and willing than for the nurse to do it. Answer 2 is not appropriate because she has said that she wants to have a natural childbirth. Answer 4 is not realistic. It is not realistic to encourage a woman in active labor to rest. Sending the husband away is not appropriate.

On the evening of the second day after birth, an infant was observed to be icteric, so he was exposed to blue light. What is the purpose of the blue light? 1. To stimulate increased formation of vitamin K in the skin 2. To enhance pigment breakdown by increasing body temperature 3. To convert indirect bilirubin to a less toxic compound 4. To increase brain electrical activity by stimulating the optic nerve

3. The bili light or blue light enhances the breakdown of indirect bilirubin to a less toxic compound. Vitamin K is not made in the skin; it is made in the intestines. Vitamin D is absorbed by the skin. Increasing temperature does not enhance pigment breakdown. The eyes are covered when the blue light is used to protect the eyes against damage.

A pregnant woman tells the nurse that she is planning to breastfeed because "You don't have to take contraceptives until you wean the baby." What is the best response for the nurse? 1. "Lactation does suppress ovulation, so you are not likely to get pregnant." 2. "You will not get pregnant until you start to menstruate again." 3. "When a woman is breastfeeding, she may not menstruate, although she may ovulate. It is best to use some type of birth control." 4. "You will find that you won't be interested in resuming sexual activity until after you wean the baby."

3. The bottle-feeding mother's ovulation and menstrual cycle has been noted to occur as early as 36 days; the breastfeeding mother's cycle can occur as early as 39 days. Lactation sometimes, but not always, suppresses ovulation. A nursing mother may ovulate and not menstruate, so another method of contraception is recommended. Lactation does not have an effect on sexual desire. Breastfeeding is not a reliable method of contraception.

A 25-year-old woman is four months pregnant. She had rheumatic fever at age 15 and developed a systolic murmur. She reports exertional dyspnea. What instruction should the nurse give her? 1. "Try to keep as active as possible, but eliminate any activity that you find tiring." 2. Carry on all your usual activities, but I learn to work at a slower pace." 3. "Avoid heavy housework, shopping, stair climbing, and all unnecessary physical effort." 4. "Get someone to do your housework, and stay in bed or in a wheelchair."

3. The client reports exertional dyspnea. The answer relates to avoiding exertion or things requiring extra effort. The data do not suggest that it is necessary at this point to stay in bed or in a wheelchair. Answers 1 and 2 do not relate to the data, which include exertional dyspnea.

A new mother who has been breastfeeding her infant for six weeks calls the nurse at the doctor's office and says her right nipple is cracked and sore; she has a temperature and feels as though she had the flu. How should the nurse respond to the woman? 1. "Try putting warm compresses over your right breast." 2. "Immediately stop nursing and apply cold compresses to your breasts." 3. "Come to see the physician. You may need medication to help." 4. "Reduce the time the baby nurses on your right breast, and call again if the breast is not better in two days."

3. The data suggest that the mother has mastitis. Antibiotics may be a part of the treatment. She should be seen by the physician. Warm compresses might be helpful, but the woman needs to be seen by the physician. Cold compresses are not indicated for infection. She will probably not need to stop nursing or reduce feeding on that breast.

An oxytocin challenge test is ordered for a woman who is 42 weeks pregnant. What should the nurse plan for in the care of this client? 1. Place her in the supine position during the test. 2. Keep her NPO before the test. 3. Have her empty her bladder before the test. 4. Prepare the client for the insertion of internal monitors.

3. The mother should empty her bladder before oxytocin is given and contractions begin. It is not necessary to be supine; the head will be elevated. NPO is not essential. The monitor with an oxytocin challenge test is external, not internal.

A newborn infant is with his mother, who is a diabetic. He appeared pink and alert and his temperature was stable when he left the nursery 15 minutes ago. His mother calls the nurse and says, "Look at his legs." The nurse observes spontaneous jerky movements. What is the best INITIAL action for the nurse to take? 1. Tell his mother that this is normal behavior for a newborn 2. Tell the mother to feed him his glucose water now 3. Do a Dextrostix test on the infant 4. Take the baby back to the nursery and observe him for other behaviors and neurological symptoms

3. The nurse needs more data on which to make an assessment. Dextrostix will test for blood sugar. The baby of a diabetic mother is apt to develop hypoglycemia. If the blood sugar is 35 mg/dL or less, he will be given glucose water, and the physician will be notified. Jerky movements of the extremities are not normal and suggest hypoglycemia.

A 32-year-old, gravida 2, para 1, term 1, preterm 0, abortion 0, living 1, is admitted to the labor room. Her previous delivery was a normal, spontaneous vaginal delivery without complications. She has been having contractions for four hours at home. The registered nurse examines her and determines that she is 4-cm dilated and 70% effaced. The fetus is in the breech position. She calls for the nurse saying, "My water just broke!" What should the practical nurse do initially? 1. Notify the physician. 2. Do a vaginal exam. 3. Check the fetal heart rate. 4. Prepare for delivery.

3. The practical nurse should initially check the fetal heart rate, and then the registered nurse (RN) should perform a vaginal exam. A breech fetus is at high risk for a prolapsed cord when the membranes rupture. Following assessment of the fetal heart rate, the RN will perform a vaginal exam. A woman with a breech presentation may need a cesarean delivery. After the initial assessments, the physician will be notified because this baby is in a breech position. The physician is not automatically notified when the membranes rupture.

An antepartal client asks when her baby is due. Her last menstrual period was August 28. Using Naegele's rule, calculate the estimated date of delivery. 1. May 21 2. May 28 3. June 4 4. June 28

3.Add nine months or take away three months and then add seven days. August 28 minus three months is May 28. Adding seven days would make it May 35. Since there are only 31 days in May, the days are carried into June—making June 4 the expected delivery date. Answer 1 subtracts seven days instead of adding seven days. Answer 2 does not add seven days. Answer 4 subtracts only 2 months instead of 3 months and does not add seven days.

A woman who is 38 weeks gestation tells the nurse that she sometimes gets dizzy when she lies down. Which information is it important for the nurse to give the client? 1. This is a sign of a serious complication and should be reported to the physician whenever it occurs. 2. Try to sleep in an upright position on your back to prevent the dizziness. 3. Try lying on your left side rather than on your back. 4. Sleeping on your back with several pillows should help.

3.Dizziness when lying on the back suggests that she may have vena caval syndrome—pressure on the vena cava from the enlarged uterus and fetus that decreases venous return and causes the blood pressure to drop. Lying on the left side usually reduces pressure on the vena cava and prevents the drop in blood pressure and dizziness. Sleeping in an upright position on her back will cause vena caval syndrome. Sleeping on the back with several pillows is similar to answer 2, which was incorrect.

When assessing a newborn's need for oxygen, which of the following should the nurse assess because it is the best indicator? 1. Respiratory rate 2. Skin color 3. Pulse rate 4. Arterial pO2

4. Arterial pO2 is the best indicator of oxygen levels. Respiratory rate, skin color, and pulse rate can be affected by factors other than oxygenation. They are indicators but are not the most reliable.

The fetus is in the breech position. Inspection of the amniotic fluid after the membranes rupture shows a greenish-black cast to the fluid. What is the best interpretation of this finding? 1. The baby is in acute distress. 2. The fluid is contaminated with feces from the mother. 3. The mother has diabetes mellitus. 4. It may be normal since the baby is presenting breech.

4. Breech presentations frequently have amniotic- stained fluid. Amniotic-stained fluid in a vertex presentation is a sign of fetal distress. Maternal diabetes does not cause amniotic-stained fluid unless the fetus happens to be in distress.

Which area of health teaching will a new mother be most responsive to during the taking in phase of the postpartum period? 1. Family planning 2. Newborn care 3. Community support groups 4. Perineal care

4. During the taking in phase, the mother is more self-centered. She will be most responsive to perineal care. She will be most responsive to family planning and newborn care during the taking hold phase. Awareness of community support groups would be in the taking hold or letting go phases.

A pregnant woman is admitted to the hospital. Her initial admitting vital signs are blood pressure 160/94; pulse 88; respirations 24; and temperature 98°F. She complains of epigastric pain and headache. What should the nurse do initially? 1. Insert an indwelling catheter. 2. Give Maalox 30 cc now. 3. Contact the doctor stat with findings. 4. Provide supportive care for impending convulsion.

4. Epigastric pain and headache suggest that a seizure is imminent. Supportive care to protect the client from injury is essential. An indwelling catheter may be inserted but only after the nurse ensures that the client is safe should a seizure occur. The epigastric pain is most likely related to preeclampsia, not gastritis. The doctor should be notified, but the client should be made safe first.

A 29-year-old woman who is pregnant for the first time and is 40 weeks gestation is admitted to labor and delivery. She is 3-cm dilated, 80% effaced, and head at 0 station. She and her husband have been to prepared childbirth classes and are eager to give birth naturally. During her first contraction in the hospital, which lasts 30 seconds, the nurse observes the client using rapid pant-blow breathing. What is the most appropriate response for the nurse to make at this time? 1. "Don't pant. It's too early in labor for panting." 2. "Continue using pant-blow breathing until the RN checks to see if you are fully dilated." 3. "Good. You are using your breathing from class. Keep it up." 4. "What kinds of breathing techniques did you learn in childbirth class?"

4. Panting is not the appropriate breathing pattern at this time. Panting is important when the woman has the desire to push but she should not push. Further assessment is needed to help her alter her breathing to a more appropriate pace. If she continues panting at this time, she will be at risk for developing respiratory alkalosis and exhausting herself. Answer 1 is a true statement but is a put-down to the client. Answer 2 is not correct. Her contractions are not compatible with late first stage of labor (transition), when the pant- blow breathing pattern is appropriate. Answer 3 is not correct. She is using an inappropriate breathing technique.

The nurse is caring for several immediate postpartum women. Which client should the nurse attend to first? 1. A woman who had a cesarean delivery asks for a drink of water. 2. A woman who had a natural child birth says she needs to urinate. 3. A woman whose baby is nursing says her uterus hurts. 4. A woman says her bed suddenly feels wet beneath her bottom.

4. The woman who reports her bed suddenly feeling wet beneath her bottom may be hemorrhaging. This needs to be checked out first. The other situations are all probably normal events. The woman who had the cesarean delivery has been NPO for several hours and is probably thirsty. The woman who had the natural childbirth may well need to urinate. The baby nursing stimulates oxytocin and uterine contractions.

A 26-year-old, gravida 3, para 0, term 0, preterm 0, abortion 2, living 0 in early labor is admitted to labor and delivery. She is not sure if her membranes have ruptured. She has had some leakage of fluid. How should the nurse begin the assessment? 1. "Tell me about your other labor experiences." 2. "How old are your other children?" 3. "Did you bring an example of the fluid that was leaking with you?" 4. "Describe your contractions to me."

4. This is the appropriate assessment in early labor. Because she is para 0 and abortion 2, the nurse knows that she has not carried a pregnancy at least 20 weeks. She has not had labor and has not given birth, so answers 1 and 2 are not appropriate. It is not reasonable to expect the woman to bring a sample of the fluid with her.

The nurse is observing a new mother for good maternal-infant attachment. Which observation would be a sign of inappropriate attachment? 1. Calling the baby "little bit." 2. Holding the baby in "en face" position. 3. Telling the baby, "You look just like your daddy." 4. Continually saying, "I'm too tired to hold the baby."

4. This may mean she is rejecting the baby. Nicknames, holding the baby in "en face" position (so the mother can look at the baby's face), and seeing family resemblance are positive signs of attachment.

The mother of a 3-lb preterm infant has expressed a desire to breastfeed her baby. Because of his prematurity, she expresses fear that she can't. What is the best response for the nurse to make? 1. "The baby won't be able to nurse for several weeks, but you can try at that time." 2. "Breast milk does not have enough calories for premature babies." 3. "You must be very disappointed that he is so small. Special formula is necessary. Perhaps you can nurse your next baby." 4. "Breast milk is very good for premature babies. Even if he is not strong enough to nurse now, we will help you pump your breasts and give him the milk."

4. This response helps to reinforce the mother's positive feelings as well as gives correct information. Answer 1 denies the mother's feelings and does not give correct information. Answers 2 and 3 are not correct. Breast milk is the best food for premature babies.

A newborn is thought to have toxoplasmosis. The nurse explains to the family that toxoplasmosis is most likely to have been transmitted to the infant in which manner? 1. Through a blood transfusion given to the mother 2. Through breast milk during breastfeeding 3. By contact with the maternal genitals during birth. 4. It crosses the placenta during pregnancy.

4. Toxoplasmosis is transmitted from the mother to the baby through the placenta. The mother most likely acquired it from cat feces or eating raw meat. The mother could contract HIV or hepatitis from a blood transfusion. HIV could then affect the fetus. HIV can probably be transmitted through breast milk. Gonorrhea, chlamydia, and herpes can all be picked up by the infant during the birth process.

A woman is admitted with suspected placenta previa. What test does the nurse expect will be done to confirm the diagnosis? 1. Internal exam 2. Nonstress test 3. Oxytocin challenge test 4. Ultrasound

4.A sonogram will show the position of the placenta in the uterus. An internal exam will probably not be done because it can cause severe bleeding when there is a placenta previa. The nonstress test and the oxytocin challenge test are done to see how the fetus responds to contractions.

A pregnant 16-year-old asks the nurse if she should have an abortion. How should the nurse respond initially? 1. "You should ask your parents for advice." 2. "Abortion is the deliberate killing of a human being." 3. "An abortion would let you finish growing up before you have children." 4. "What are your feelings about abortion?"

4.The nurse should initially encourage the client to formulate and express her thoughts and concerns. The nurse should not try to impose her or his values on the client, as answers 2 and 3 do. Answer 1 tells the client what to do and is not appropriate for an initial response, although discussing the issue with her parents should be encouraged.