Complicated SGQ w/ rationale
All of the following statements regarding venous thromboembolic disorders are true except? A.) DVT occurs most often in the postpartum period, and PE is more common during pregnancy B.) The risk for venous thromboembolism nearly doubles in patients who have undergone a C-section C.) Patients with pulmonary emboli commonly present with dyspnea, hemoptysis, and chest pain D.) Nurses should teach mothers that neither heparin nor warfarin is excreted in significant amounts in breast milk Answer: A
False- DVT occurs most often during pregnancy, and PE (pulmonary embolism) is more common in the postpartum period True- Cesarean birth nearly doubles the risk for VTE; therefore, routine preoperative placement of pneumatic compression devices is recommended True- Presenting symptoms are dyspnea and tachypnea. Other S/S frequently seen are tachycardia, apprehension, pleuritic chest pain, cough, hemoptysis, elevated temperature, and syncope True- If the woman is breastfeeding, she is informed that heparin and warfarin are not excreted in breast milk in significant quantities
It is found that a newborn baby's blood type is B positive. Which of the following mother's blood types would put the baby at risk of hemolytic jaundice? A positive B negative AB positive O negative
A) Incorrect. Hemolytic jaundice form ABO incompatibility is rarely seen in infants with type B blood born to mother with type A blood B) Incorrect. Hemolytic jaundice form ABO incompatibility is rarely seen when the maternal blood type is anything other than type O. Rh incompatibility can occur only If the mother is Rh-negative and the baby is Rh-positive. C) Incorrect. Hemolytic jaundice form ABO incompatibility is rarely seen when the maternal blood type is anything other than type O. D) Correct. It occurs if the fetal's blood type is A, B, or AB, and the maternal type is O. The incompatibility arises because naturally occurring anti-A and anti-B antibodies are transferred across the placenta to the fetus. Unlike the situation that pertains to Rh incompatibility, first born infants can be affected because mothers with type O blood already have anti-A and anti-B antibodies in their blood. (PWC: A maternal blood type of B negative (answer b) can also result in hemolytic disease of the newborn. A newborn who is Rh positive born to a mom who is Rh negative can be at risk for severe jaundice related to Rh incompatibility. Also, a baby who is B positive, born to a mom who is O negative is more at risk from the Rh incompatibility rather than the ABO incompatibility. ABO incompatibility is much less serious than the Rh incompatibility.)
The nurse is receiving report about a neonate suspected of having Respiratory Distress Syndrome (RDS). Which finding would the nurse anticipate? A. Intercostal retractions B. PaCO2 of 42 mmHg C. Pink, warm skin D. PaO2 of 78mmHg
A. Correct. Clinical symptoms of RDS include "crackles, poor air exchange, pallor, the use of accessory muscles (retractions) and, occasionally, apnea" (Lowdermilk, 2012, pp. 915). B. Incorrect. This is a normal finding for arterial blood gas values for neonates. Normal values include: pH = 7.35-7.45, PaO2 = 60-80mmHg, PaCO2 = 35-45mmHg, HCO3 = 18-26mEq/L, O2 sat = 92%-94% (Lowdermilk, 2012, pp. 916). C. Incorrect. Clinical symptoms of RDS include "crackles, poor air exchange, pallor, the use of accessory muscles (retractions) and, occasionally, apnea" (Lowdermilk, 2012, pp. 915). D. Incorrect. This is a normal finding for arterial blood gas values for neonates. Normal values include: pH = 7.35-7.45, PaO2 = 60-80mmHg, PaCO2 = 35-45mmHg, HCO3 = 18-26mEq/L, O2 sat = 92%-94% (Lowdermilk, 2012, pp. 916).
After the nurse assesses each of her four postpartum patients, which of the following patients should not receive methylergonovine maleate (methergine)? A. The patient with a white blood cell count of 23,000. B. The patient with a temperature of 100 degrees Fahrenheit. C. The patient with a blood pressure of 154/92. D. The patient with a hemoglobin level of 10.
A. INCORRECT. A WBC count of 23,000 is not a contraindication for methergine and is a normal lab value for a postpartum patient. (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., p. 827) B. INCORRECT. It is normal for a postpartum patient to have a slightly elevated temperature. This is not a contraindication for methergine. (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., p. 827) C. CORRECT. Hypertension is a side effect of methergine, and is a contraindication to administering the medication. (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., p. 827) D. INCORRECT. Methergine will help prevent the hemoglobin from decreasing further by promoting uterine contractions. A hemoglobin level of 10 is not a contraindication to the medication. (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., p. 827)
The nurse is caring for a couplet in the postpartum unit. A healthy, full term, baby boy was delivered yesterday to a primagravida who experienced an uncomplicated pregnancy and forceps assisted vaginal delivery. Which newborn assessment does the nurse recognize is important to perform throughout her shift based on this information? A. Head circumference B. Deep tendon reflexes C. Weight D. Intake and output
Answer: A Rationale: A forceps assisted delivery increases the risk for intracranial hemorrhage, which can be devastating if not detected and treated early. Head circumference should be carefully monitored for at least the first 48 hours after a forceps assisted delivery. (B), (C), and (D) are not of high priority based on the information provided.
Which of the following is not a potential result of an aging placenta in a post term birth? A: the fetus can have altered nutrient and oxygenation transport B: the fetus can have a wasted appearance by birth C: the fetus may be hyper oxygenated at birth D: the fetus is at risk for hypoglycemia during labor
Answer: C Rational: A: this is caused by placental insufficiency due to an aging placenta B: this is caused by placental insufficiency due to an aging placenta C: an aging placenta can cause a fetus to be hypoxic during pregnancy and labor D:this is caused by placental insufficiency due to an aging placenta
Following a vaginal delivery, the nurse calculates the EBL to be 700 mL. Assessment findings reveal the following: heart rate is 125 beats per minute, respiratory rate is 18/minute, blood pressure is 83/44, temperature is 100.4 degrees F, and oxygen saturation is 90%. Which order would the nurse question for this patient? A: Type and Crossmatch for 2 units of PRBC's STAT B: Administer oxygen to maintains SpO2 ≥ 95% C: Discontinue vigorous fundal massage D: Take vital signs Q 5 minutes including LOC and SpO2
Answer: C, Discontinue vigorous fundal massage. Rationale: The assessment findings include cumulative blood loss > 500 mL during and following a vaginal birth, HR>110, BP≤ 85/45, and O2 sats≤ 95%, which indicate early OB hemorrhage. These findings require the nurse to proceed to stage 1 of the OB hemorrhage guidelines for care. These guidelines indicate that the nurse should continue vigorous fundal massage, not discontinue it. They also indicate that the nurse should type and crossmatch for 2 units of PRBC's, Administer O2 to keep sats above 95%, and take VS including LOC and SpO2 Q 5 minutes. (PWC: COLLAPSE This is correct based on the CMQCC guidelines and definition of OB hemorrhage. Typically you will not see such dramatic changes in vital signs with a 700 mL blood loss. These changes are more associated with a 1500 mL blood loss and greater. It's always possible that the EBL has been underestimated, however, so it's important to pay attention to and respond to the patient status.)
Upon assessment of a full-term Asian-American newborn, the nurse notes yellow discoloration of the skin and mucous membranes. Which extra assessment finding could lead the nurse to suspect physiologic jaundice rather than pathologic jaundice? A) Serum bilirubin concentration is greater than 5 mg/dl in cord blood. B) The mother was Rh-negative while the fetus was Rh-positive. C) The newborn began demonstrating signs of jaundice 72 hours after birth. D) Serum bilirubin has remained higher than 12.9 mg/dl since birth.
Answers: False. This is indicative of pathological jaundice. False. One of the most common causes of pathological jaundice is hemolytic diseases, such as Rh incompatibility. True. Signs of pathological jaundice appear within the first 24 hours after birth, while signs of physiologic jaundice appear after 24 hours and peak between 72 and 120 hours in Asian-American infants. False. A serum bilirubin level of greater than 12.9 mg/dl at any given time in a term infant is supportive of pathologic jaundice. (PWC: Your book does state that a level of greater than 12.9 in a term newborn at any time is suggestive of pathological jaundice. However, if you use the AAP hour-specific nomogram (bilitool.org) to analyze risk, this level would come out to be "low intermediate risk" for a term newborn who was 72 hours old. It would be a different story if the newborn was only 36 hours old.)
During a birth preparation class, an experienced nurse teaches about cesarean births. Which statement made by a primigravida taking the course demonstrates an understanding of the topic? A: "I don't need to be concerned about the reasons and complications of cesarean births. I plan on giving birth vaginally." B: "I don't want a cesarean birth, because general anesthesia will be given. I want to be awake for the birth of my baby." C: "I want an elective cesarean birth, because it can help prevent urinary and fecal incontinence later in life." D: "I'm not choosing an elective cesarean, because it can increase the risk of complications with future children."
Answers: D D: True. Cesarean birth is not recommended if mothers want to have multiple children, because it can increase the risk of placenta previa, placenta accreta, and cesarean hysterectomy."
After assessing a 26-year-old woman who just gave birth to a healthy baby boy, the nurse suspects that the woman may have endometritis. All of the following assessment findings provide evidence of this particular postpartum infection except for? A: Fever greater than 38 degrees Celsius B: Nonfoulsmelling, scant lochia C: Pelvic pain and uterine tenderness D: Increased pulse, chills, anorexia, and fatigue
CORRECT: B B) CORRECT: A common assessment finding for endometritis is fouling smelling, profuse lochia (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., p. 834).
A primigravida is admitted with uncontrolled vomiting, dehydration, and weight loss of 5 lbs. over the past 2 weeks. Which of the following orders would the nurse caring for the patient carry out first? (A.) Administer Dextrose 5% in ½ NS PRN hypoglycemia (B.) Progress to clear liquid diet as tolerated (C.) Administer 1000mL Lactated Ringer's over 18 hours with 40 mEq of KCl & added vitamins B1 and B6 (D.)Provide patient education regarding management of hyperemesis gravidarum
CORRECT: C Rationale: IV Fluids with KCl, Vitamins B1 and B6 should be administered first to correct dehyradation as well as electrolyte imbalances and vitamin deficiencies associated with hyperemesis gravidarum. The woman should also be placed on NPO status initially, so answer choice B is not yet indicated. Answer choice A is incorrect because the patient's thiamine deficiency must be addressed before administering dextrose solution, which if administered first could precipitate Wernicke encephalopathy. Although D is needed at some point, it is not as urgent as the need to correct fluid and electrolyte imbalances. (PWC: While your current course textbook states nothing about particular IV solutions, typically we would run any IV for hyperemesis over an 8-hour period (125 mL/hr), not 18 hours.)
The nurse has admitted a primagravida client who is concerned that she is going into labor. The client is at 34 weeks gestation. Which of the following findings would confirm the nurse's suspicions that the client has progressed to active preterm labor? A: Cervical dilation of 3 cm B: Contraction frequency every 15 minutes. C: Effacement at 30%. D: Irritable uterus
Correct : A According to Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., "The diagnosis of preterm labor is based on three major diagnostic criteria: Gestational age between 20 and 37 weeks, Uterine activity (e.g., contractions), Progressive cervical change (e.g., effacement of 80%, or cervical dilation of 2 cm or greater)" (p.783) B Is incorrect because in order to fit the criteria, uterine contractions should occur more frequently than every 10 min persisting for 1 hour or more. C is incorrect because in order to progress to active preterm labor, there needs to be cervical effacement of at least 80% D is incorrect because a pregnant woman with "an irritable uterus but no documented cervical change is not in preterm labor, though she should be carefully evaluated during follow-up care to determine whether she has progressed to active preterm labor" (PWC: This is kind of a tricky question, because the criteria for diagnosis of preterm labor states "progressive cervical change". That means that we need to have at least two cervical exams at least an hour apart to determine if the cervix has changed. The other thing is that, to really confirm preterm labor, we need to meet all the criteria (gestational age between 20 and 36 6/7 weeks, uterine contractions, and progressive cervical change). The question did not mention that she was having contractions. However, when a woman at 34 weeks gestation is having contractions and her cervix is 3 cm dilated, we can presume that her cervix has changed. It would certainly raise our suspicions, but it would not confirm our suspicions. This patient would probably receive IV hydration and be monitored for several hours. If she continued to contract, despite the hydration, and her cervix changed, would could THEN confirm that she was in preterm labor.)
A 19-year-old primigravida patient at 36 weeks' gestation is receiving a continuous infusion of magnesium sulfate to treat severe preeclampsia. To ensure patient safety, what would be the priority nursing intervention? A) Assess reflexes, clonus, visual disturbances, and headache B) Encourage husband to remain at bedside C) Begin external followed by internal fetal monitoring D) Request for ABGs to be drawn immediately
Correct Answer: (A) Rational: A) Central nervous system (CNS) functioning and freedom from injury is of highest priority in maintaining the well-being of both the mother and the infant. If CNS function is not properly assessed and action is not taken, the mother is at risk of suffering CNS damage related to hypertension or stroke. (PWC: Just to clarify, while the question seems to focus on what you'd watch for regarding magnesium sulfate infusion, the correct answer and rationale address severe preeclampsia. While decreased reflexes are also a sign of mag toxicity, clonus, visual disturbances and headaches are not. Things we need to monitor for regarding mag toxicity would be reflexes, respirations, urine output, and LOC.)
A G2P2003 woman is 8 hours s/p spontaneous vaginal delivery and is recovering from the effects of the epidural. Upon assessment the nurse finds edema of the right legs and pain upon palpitation. After notifying the doctor, he diagnoses the woman with a DVT. The doctor has prescribed orders for the nurse to follow. Which of the following orders should the nurse question? A: 200 mg Aspirin PO q6hours B: Local application of moist heat C: Heparin 1300 units/hr IV D: Bed rest with affected leg elevated
Correct Answer: A Rational: Medications containing aspirin are NOT given to women receiving anticoagulant therapy such as heparin. Aspirin inhibits synthesis of clotting factors and can prolonged clotting time and increase the risk of bleeding (Lowdermilk, Perry, Cashion, & Alden, 2012, pp. 833) All of the other choices are correct in the initial medical treatment of a DVT. (PWC: Since this woman is G2P2003, this would imply that she had twins during one of her pregnancies, however you have not mentioned which pregnancy. Makes me wonder if it was a typo? That is important information to add to this question. Also, it would not be normal for her to be recovering from the epidural 8 hours later. Was there a problem?)
A 25 year old G1P0 presents to the clinic at 35 weeks gestation and states "I am having a lot of clear fluid coming out". The doctor quickly diagnoses her with preterm premature rupture of membranes (preterm PROM). The doctor determines that the mother and baby are not at immediate risk and writes discharge orders. The nurse is performing discharge teaching about home care management of premature PROM. Which of these statements, made by the patient, indicates that teaching was effective? A. "I can resume sexual activity as soon as I get back home." B. "After using the restroom I will wipe from front to back." C. "I will assess my pulses once a day." D. "It is a good idea to soak in a tub to help relieve stress."
Correct Answer: B A. Incorrect: After a woman experiences premature PROM the woman should NOT engage in sexual activity. B. Correct: The woman should wipe from front to back after using the restroom to help prevent infection. C. Incorrect: The woman should assess her pulse every 4 hours when awake. D. Incorrect: The woman should not soak in a tub after being diagnosed with preterm PROM. This could cause infection which needs to be avoided for her and baby's health. (PWC: The current edition (11th ed) of this textbook states that conservative management of PPROM is not recommended for women who are beyond 34 weeks gestation. This risk of infection (chorioamnionitis) supersedes the risk to the newborn who is born at this gestational age. I can also tell you that in all my years of working in L&D (16 years), I have never seen a physician send a patient home with ruptured membranes. They risk infection, prolapsed cord, and preterm birth at home. Current practice for a patient at 35 weeks with ruptured membranes would include induction of labor. If they are earlier than 34 weeks, then they might try to delay birth for at least 48 hours so that steroids may be given (to help prevent RDS in the newborn).)
A nurse is explaining to a pregnant patient the importance of recognizing signs and symptoms of preterm labor during a prenatal visit. All of the following are signs and symptoms that the nurse would teach the pregnant patient to recognize, EXCEPT: A. Lower abdominal cramping similar to gas pains B. Sharp, continuous low back pain C. A change in character or amount of usual discharge D. Uterine contractions that are painful or painless
Correct Answer: B Rationale: Because more than half of preterm births occur in women without obvious risk factors, it is essential that all pregnant women be taught the symptoms of preterm labor. The correct answer to this question (B) would not be a sign or symptom of preterm labor; instead, the pregnant woman would experience dull, intermittent low back pain below the waist. All of the other answer choices (A, C, D) would indicate symptoms of possible preterm labor that should be assessed at each prenatal visit.
The nurse is speaking with the parents of a term newborn that was diagnosed with clubfoot. The nurse is providing teaching about the cast that the newborn will receive. Which statement by the parents indicates that teaching was effective? A. "The cast that is placed on my child, before we leave the hospital, will be removed one month from now" B. "The initial cast will be placed on my child one month after discharge to allow time for the foot and leg to grow" C. "I will check my child's toes, of the casted foot, for a capillary refill of <3 seconds to ensure there is good circulation" D. "If needed, the surgery to correct my child's clubbed foot will be performed after my child is already walking"
Correct Answer: C Rationales: A. This is incorrect because the initial cast is replaced every week. B. This is incorrect because the cast is placed before discharge from the hospital. C. This is correct because the foot and leg are growing rapidly and checking capillary refill is a good indication of neurovascular health within the cast. D. This is incorrect because surgery is performed before the child is able to walk.
A mother with type 1 diabetes has just delivered a newborn diagnosed with fetal macrosomia. Upon assessment of the newborn, the nurse is likely to note all of the following typical characteristics of macrosomia EXCEPT: A. A round, cherubic face B. A plethoric or flushed complexion C. Splenomegaly and cardiomegaly D. An enlarged brain
Correct Answer: D Rationale: Infants born to mothers with diabetes are at an increased risk for complications. The incidence of fetal macrosomia is 40% in women with type 1 diabetes, despite improvements in the control of maternal blood glucose levels. The correct answer to this question (D) would not be a typical characteristic of macrosomia. Because insulin does not cross the blood-brain barrier, the brain is the only organ that is not enlarged. All of the other answer choices (A, B, C) are typical characteristics of fetal macrosomia.
The nurse is caring for a 23 year old primagravida in active labor whose gestational age is estimated at 43 weeks 2 days. The patient asks the nurse if it is concerning that she has lost about 3 lbs in the past week. The nurse explains to the patient that some weight-loss is expected in post-term gestations and that she should not be concerned. However, the nurse knows that there is an increased risk for which of the following based on this statement? A. Maternal injury due to macrosomic infant B. SGA infant due to placental insufficiency C. Fetal hypoxia due to cord compression D. Maternal exhaustion due to depleted energy reserve
Correct answer: (C) Maternal weight loss of about 3 lbs/week can occur after 42 weeks of gestation, and is due to decreased amniotic fluid. A common complication of post-term gestation is oligohydramnios, or decreased amniotic fluid (less than 400 mls). Inadequate fluid volume can lead to compression of the umbilical cord, resulting in fetal hypoxia. While the risk for abnormal fetal growth (A) and (B) is increased in post term gestations, the patient's weight loss is not indicative of either a macrosomic or small for gestational age infant. (D) is not a common complication of post-term labor. (PWC: It's important for you to know that a weight loss of up to 3.5 lbs also can occur right before labor as a result of electrolyte shifts. So, which is it with this patient, since she is in labor? Furthermore, no physician would allow a patient to get to 43 weeks and 2 days! Most physicians will induce at 41 weeks. Also, because weight loss at this gestational age can be a sign of concern, would you really want to tell the patient that it is nothing to worry about? Instead wouldn't you want to tell her the truth, but add that you are monitoring the baby closely (non-stress test)? In addition, if she didn't already have her bag of water broken, you would tell her that the physician will probably do that soon in order to assess the color of the amniotic fluid (based on the knowledge that postterm births with low amniotic fluid are at great risk for meconium stained amniotic fluid).
The nurse is performing an assessment of a newborn baby girl and recognizes a change in the infant's temperature from 98.2 oF to 96. 3 oF. The mom explains that her baby was feeling warm to the touch so she left her unswaddled in her bassinette to cool her down. Which of the following additional assessment findings would lead the nurse to believe cold stress is setting in? A. Blood glucose level greater than 50 mg/dL. B. Acrocyanosis C. Respiratory rate of 80 breaths per min D. Flushed or red skin
Correct answer: C Rationals: A is incorrect because, "the process of anaerobic glycolysis uses approximately three to four times the amount of blood glucose, thereby depleting existing stores." (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., p. 534) The infant would be showing decreased glucose levels which would show the most significance as a decreased value below the standard of 50 mg/dL. B is incorrect because, "Acrocyanosis is a normal finding in the neonate, but central cyanosis indicates an underlying problem that requires further evaluation." (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., p.896) The finding of tachypnea indicating respiratory distress is the most common sign of cold stress and should be considered more significant. C is correct because babies who have cold stress syndrome will develop respiratory distress. A hallmark symptom of cold stress is respiratory distress manifested as and increased respiratory rate called tachypnea. "Respiratory rate will increase in response for a need for oxygen" in order to maintain normal brain and cardiac function. (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., p. 534) D is incorrect because according to table 37-2 on p. 897 in our Maternity and Women's Health Care by Lowdermilk, Perry, Cashion, and Alden (2012), flushed or red skin is an indication of hyperthermia which is the opposite of hypothermia.
A postpartum woman presents to the emergency department 72 hours after giving birth with a fever of 101.2°F, increasing pelvic pain, anorexia, nausea, fatigue, and foul-smelling, profuse lochia. Which of the following postpartum infections would the nurse would be most concerned that the patient has contracted? A: An infection of the lining of the uterus B: An infection at the site of cesarean incision C: An infection of the urinary tract D: An infection of the breast tissue
Correct: A A) CORRECT. The signs of endometritis, infection of the lining of the uterus, often include a fever (usually >100.4°F), increased pulse, chills, anorexia, nausea, fatigue, pelvic pain, uterine tenderness, and foul-smelling, profuse lochia. B) INCORRECT. The signs of wound infection often include fever, erythema, edema, warmth, tenderness, pain, seropurulent drainage, and/or wound separation at the site. C) INCORRECT. A urinary tract infection often includes signs and symptoms of a low grade fever, urinary retention, hematuria, and pyuria. D) INCORRECT. Mastitis, or breast infection, often presents with symptoms of fever, malaise, flulike symptoms, and a sore area in a breast.
Which statement by the mother indicates further teaching is required regarding an amniocentesis? A). I should have the procedure done when I am 8 weeks pregnant B). The test can help see if my baby has any genetic disorders C). The amniocentesis can be used to assess my fetus' lung maturity D). Complications are rare, but can include placental abruption or hemorrhage
Correct: A A: Correct. An amniocentesis should be performed after week 14 of pregnancy, when the uterus becomes an abdominal organ and sufficient amniotic fluid is available for testing D: Incorrect. Complications in the mother and fetus occur in less than 1% of cases and include the following: Leaking of amniotic fluid, hemorrhage, labor, placental abruption, inadvertent damage to the intestines or bladder, and amniotic fluid embolism. Some fetal complications include: Death, hemorrhage, infection, or direct injury from needle. This statement by the mother indicates she understands the potential complications of the procedure.
A 17 year old female comes into the ED with severe abdominal pain and referred shoulder pain. The patient complains of dizziness and states that took an at home pregnancy test last week that was positive. The ED physician performs an abdominal ultrasound and diagnosed the patient with a Tubal Ectopic Pregnancy and begins Methotrexate therapy. What is the priority nursing intervention for a patient receiving Methotrexate? A. Advise the woman to avoid/discontinue all folic acid supplements and alcohol. B. Teach the client to monitor for high blood pressure while taking methotrexate. C. Administer Zofran 4mg PO Q4H PRN for nausea and vomiting before administration. D. Tell the patient that she will never be able to conceive again after receiving the medication.
Correct: A. Rationale: Taking folic acid or drinking alcohol can lead to ectopic rupture or exacerbate side effects of the medication, like bleeding, diarrhea, joint pain, & thrombocytopenia. "The woman on methotrexate therapy who drinks alcohol and takes vitamins containing folic acid (such as prenatal vitamins) increases her risk of having side effects of the drug or exacerbating the ectopic rupture" (Lowdermilk, 2012, p. 677).
A nurse is caring for a patient who is at 32 weeks gestation and has a history of rheumatic disease with mitral valve stenosis. The patient states that she is experiencing increased fatigue and difficulty breathing when performing everyday activities. Which of the following statements would indicate that the client needs further teaching? A: "I recently learned how to knit so that I have something to keep my mind occupied while I rest" B: "I think that pregnancy makes me colder than usual because sometimes my nailbeds and lips turn blue" C: "I have been working to schedule my day so that I have more time to relax between activities" D: "I'm keeping a journal that describes my activity tolerance so that I can bring it to my doctor's appointments"
Correct: B A) INCORRECT. Coming up with quiet diversional activities is recommended to decrease the potential for boredom during rest periods. B) CORRECT. Cyanosis of the lips and nailbeds is a potential sign of cardiac decompensation and should be reported to the health care provider. C) INCORRECT. Patients with a history of cardiac disease are encouraged to incorporate rest periods into their daily routine. D) INCORRECT. Keeping a log of activities, time, duration, intensity, and physiological response is a recommended practice for pregnant woman with heart disease. (PWC:Her increasing fatigue and shortness of breath with normal activity is, in and of itself, a sign of cardiac decompensation and of great concern. She needs further evaluation (echocardiogram), not just teaching about activity and rest.)
The nurse is assessing the dilation and effacement of a laboring patient. Upon assessment, the nurse notes that the cord is felt protruding from the vagina. Which of the following actions should the nurse perform first? A. Document the finding B. Call for assistance C. Assist the patient to a standing position D. Increase the rate of IV fluids
Correct: B A. Incorrect. This indicates a prolapsed umbilical cord and is an emergency. The first action of the nurse should be to call for assistance. After the emergency is resolved, the nurse may document the finding. B. Correct. The nurse should first call for assistance without leaving the patient. After this, the nurse should notify the HCP and "glove the examining hand quickly and insert two fingers into the vagina to the cervix. With one finger on either side of the cord or both fingers to one side, exert upward pressure against the presenting part to relieve compression of the cord" (Lowdermilk, Perry, Cashion & Alden, 2012). C. Incorrect. After calling for assistance, the patient may be placed in extreme Trendelenburg or a modified Sims position with pillows under the hips or a knee-chest position. The patient would not be encouraged to stand. D. Incorrect. After calling for assistance, the drip rate may be increased. Although this is a correct answer, it is not the first action the nurse should take.
A nurse is providing teaching to a Type 1 diabetic patient that recently became pregnant. Which statement by the patient suggests that further teaching is needed? A: If I don't stay on top of my sugars, my baby could potentially be too large to deliver vaginally. B: Because I have been a controlled diabetic for 5 years, I will not have to make any nutritional changes during pregnancy. C: I'll need to consult my health care provider prior to performing any regular exercise due to my pregestational diabetes. D: Pregestational gestational diabetes makes my pregnancy "high risk", and I will have to have more frequent check ups.
Correct: B A: Inccorect; this is a correct statement. Macrosomia (birth weight more then 4000 to 4500g or greater then the 90th percentile) occurs in 40% of pregestational diabetic pregnancies due to poor glycemic control later in pregnancy B: Correct; this is an incorrect statement. Pregnancy places different nutritional demands on the body; therefore, even patients with controlled pregestational diabetes will need to be educated on the dietary changes necessary in pregnancy C: Incorrect; this is a correct statement. Exercise has been proven to decease insulin need in women without diabetes; however data regarding pregestational pregnant women is limited; therefore, exercise should be prescribed by a health care provider with specific instructions
A 26-week gestation woman is being taught how to assess for signs of preeclampsia. The nurse explains to the client that she should report to her health care provider if she notices which of the following symptoms: A: She takes her blood pressure on the same arm as always while sitting on the couch at home and it is 118/78. B: She takes a dipstick test to assess proteinuria and her proteinuria is 2+ and she notices an overall decrease in urinary output. C: While completing her baby's daily activity assessment in the morning, as always, she notices the baby is very active. D: The woman notes that she can feel irregular and intermittent contractions throughout the day and is concerned she is going into labor.
Correct: B B) This answer is CORRECT. The woman should contact her health care provider, as this is a sign of preeclampsia. (PWC: While proteinuria on a diptstick of 1+ or more is a sign of preeclampsia, this is not something we would ask a patient to test at home. Furthermore, are you asking her to measure her urine? That is not realistic and, without doing this, how will she know that she has decreased urinary output? We also would not ask a patient to invest in a BP cuff to measure her BP at home. Signs that a patient can monitor are: headache that won't go away with a couple of Tylenol, visual disturbances, and epigastric or RUQ pain. These are all subjective symptoms that a patient can monitor without difficulty.)
The nurse is providing care for a 25 year old primigravida patient who is currently in her second trimester. She presented to the hospital after she noticed a small amount of painless bright red vaginal bleeding and is later admitted to the hospital for placenta previa. Which order would the nurse question when providing care for this patient? A. Bed rest with bathroom privileges and limited activity. B. Vaginal exams Q12H to assess bleeding. C. Monitor vital signs Q4H. D. Send blood sample to lab for CBC and cross-matching.
Correct: B B. Correct- A patient experiencing placenta previa will be on "pelvic rest". No vaginal exams, douching, or vaginal intercourse should be performed in order to prevent bleeding. Bleeding is assessed by checking the amount of blood on perineal pads, bed pads, or linens
A client in her third trimester comes in for an antepartum check-up and is diagnosed with severe preeclampsia with HELLP Syndrome. The nurse will assess and monitor for which of the following sign and symptoms of HELLP except. A: Decreased Hemoglobin and Hematocrit B: Elevated Liver Enzymes C: Complaints of epigastric/right upper quadrant pain D: Increased platelet count
Correct: B Rational: Patients who are diagnosed with HELLP have hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP). HELLP causes endothelial damage and fibrin deposits in the liver leading to impaired functioning and elevated enzymes (Lowdermilk, Perry, Cashion, & Alden, 2012, pp. 658). The patient will also have subjective complaints of malaise, flu-like symptoms, epigastric or RUQ pain, nausea and vomiting, and headaches (PWC: If a patient is diagnosed with HELLP, we are not going to sit on her and monitor for the signs and symptoms--they are already there! Instead, we are going to deliver her. Also, while a decreased H/H is not wrong, it is not something we look for. More important labs include platelet counts, liver enzymes (which you mentioned), creatinine (shows kidney function), and uric acid. An increased bilirubin would also reflect RBC breakdown (hemolysis) better than H/H.)
A prenatal client at 5 weeks' gestation is told she had a missed abortion after confirming it by ultrasound. Which explanation by the nurse correctly describes this type of abortion? A: "This type of abortion may resolve without threatening the fetus." B: "Your internal cervical os dilated, and your membranes ruptured." C: "The fetus died in utero, and uterine growth stopped." D: "Your baby died because of the presence of infection."
Correct: C A. INCORRECT. A threatened abortion is characterized by unexplained bleeding, cramping, or backache that may indicate the fetus is in jeopardy. Bleeding may persist for days, and the cervix is closed. This type of abortion may resolve without threatening the fetus. B. INCORRECT. The internal cervical os dilates in imminent abortion. Bleeding and cramping increase and membranes may rupture. C. CORRECT. In a missed abortion, the fetus dies in utero but is not expelled. Uterine growth ceases, breast changes regress, and the woman may report brownish vaginal discharge. The cervix is closed. D. INCORRECT. Septic abortion is the correct term used for an abortion caused by infection. (PWC: We would never diagnose a missed abortion at 5 weeks. It is too early. We often cannot see a heart beat on ultrasound at this point, so we have the woman come back in 1 to 2 weeks to reevaluate. Also, at 5 weeks gestation, the baby is referred to as an embryo, not a fetus. A septic abortion is not caused by infection. Infection develops as a complication of abortion. An example would be an elective abortion done by unskilled hands or under unsterile conditions.)
A G2P1 mother with a history of preterm labor asks her doctor what she can do to help prevent preterm labor/birth from occurring. Which of the following statements made by the mother after talking with her doctor shows that she needs further education on preterm labor/birth prevention strategies. A: I will work from home from now until the end of my pregnancy. B: I will not participate in sexual activity the rest of my pregnancy. C: I can still walk my 2 y/o to the neighborhood park to play with her in the afternoons. D: While on modified bed rest I can get up to use the bathroom and shower.
Correct: C A. Incorrect, Activity restriction, including bed rest and limited work, is usually prescribed to prevent preterm birth. B. Incorrect, Restriction of sexual activity is frequently recommended for women at risk for preterm birth. C. Correct, Activity restriction is usually prescribed to prevent preterm birth. D. Incorrect, With modified bed rest, women are usually allowed bathroom privileges for toileting and showering and can be up to the table for meals. (PWC: If she has not been diagnosed with preterm labor during this pregnancy, none of this applies. We would never put a woman on such restrictions as a preventive strategy. These interventions are appropriate for a woman who has been diagnosed with preterm labor as a means to prevent preterm birth. To prevent preterm labor, the only interventions mentioned in your book are smoking cessation and progesterone supplemention.)
A woman at 36 weeks gestation with a history of maternal hypertension is admitted to the labor and delivery unit. She experiences a sudden onset of intense uterine pain with a board-like abdomen; increased uterine contractions and dark red vaginal bleeding. The nurse suspects the onset of which complication? A) Placenta previa B) Ectopic pregnancy C) Placental abruption D) Threatened miscarriage
Correct: C A. Incorrect. Placenta previa is characterized by painless bright red vaginal bleeding, and during abdominal exam the uterus is soft, relaxed and non-tender B. Incorrect. One of the main signs of ectopic pregnancy is delayed menses for 1 to 2 weeks, a lighter than usual period, or an irregular period. Abdominal pain begins as a dull lower quadrant pain that becomes severe over a period of time C. Correct. Classic symptoms of placental abruption include dark red vaginal bleeding, abdominal pain sudden in onset, and uterine tenderness and contractions. Pain is mild to severe over the uterus with a board-like abdomen. Women with a history of maternal hypertension are at a higher risk for placental abruption. D. Incorrect. Symptoms of threatened miscarriage include slight spotting with mild uterine cramping. (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 671). (PWC: I hope you all immediately eliminated answers B and D. These are both early pregnancy issues and would never present themselves in a woman who is at 36 weeks gestation.)
A nurse is providing discharge instructions to a 27 years old female who has just experienced an early miscarriage. Which statement by the patient indicates that further teaching is required? A: "I will avoid using a tampon and having intercourse for 2 weeks." B: "I will contact my doctor if I notice any foul smelling vaginal discharge." C: "I will make sure to eat foods low in iron and protein." D: "I will take only showers and not take any baths for 2 weeks."
Correct: C C) CORRECT: It is important for the woman to eat foods high in iron and protein to promote tissue repair and red blood cell replacement after experiencing an early miscarriage. Therefore, further teaching is required
A 25-year-old patient who is 30 weeks gestation has just been told she has preterm premature rupture of the membrane (preterm PROM). The nurse completed teaching to the patient about preterm PROM. Which statement by the patient would indicate that more education on the topic is needed? A: Because I have preterm PROM, I am at a higher risk for a bacterial infection in the amniotic cavity known as Chorioamnionitis B: PROM can be caused by inflammation of the amniotic membranes or stress from uterine contractions, but in most cases the cause of PROM is unknown. C: If my uterus becomes tender to touch, I should soak in a warm bubble bath to relieve discomfort. D: I should report foul-smelling vaginal discharge to my healthcare provider because it could indicate an infection.
Correct: C C) Correct: This statement is incorrect and would indicate that more teaching is needed. If a patient with preterm PROM is having uterine tenderness, she should immediately report this to her healthcare provider. A patient with preterm PROM should not soak in a bath because it increases her risk of an infection.
A first time mother is in for her newborn's first check up appointment. She is now 2 weeks postpartum and concerned that she is not being a good mother to her baby. The nurse is providing teaching for the patient in regards to signs and symptoms of postpartum depression. Which of the following questions would NOT be appropriate to ask this patient? A: Do you feel sad and notice that you are crying frequently? B: Have you had trouble sleeping since the baby was born? C: Do you notice more focus on yourself rather than your baby? D: Do you have feelings of worthlessness or inadequacy?
Correct: C Not a sign of PP depression
A woman has just been admitted for a scheduled induction. Upon receiving orders, the nurse proceeds to hang IV Oxytocin (Pitocin). After explaining to the client about the purpose and side affects of this specific medication, which statements best indicates that more teaching is needed? A: "This medication will help stimulate my contractions and aid in milk let-down" B: "Oxytocin is something that my own body can make" C: "It is okay for me to become drowsy and nauseous, that's just the medication working" D: "I may have to be on this medication even after labor to help control bleeding"
Correct: C A: Incorrect, the main purpose of starting Pitocin is to help stimulate uterine contractions and set a good labor pattern B: Incorrect, oxytocin is indeed an hormone that is produced in the posterior pituitary gland C: Correct, this statement does indicate further teaching is needed. The patient is referring to s/s of water intoxication (hyponaterima, confusion, vomiting, and drowsiness), which is an adverse affect to Pitocin. D: Incorrect, Pitocin is frequently given postpartum to aid in controlling postpartum bleeding. (PWC: It is important for you to know that water intoxication can only occur if the oxytocin is mixed with a non-isotonic solution. Because we always mix oxytocin with either LR or NS, this never happens. Also, while the hormone is responsible for the "let-down" effect, that is not why we give the medication. Her own naturally produced oxytocin will be released to stimulate the let-down as the baby sucks.)
A 24 year-old primigravida at 32 weeks gestation presents to the ED with pelvic pain, urinary frequency, and pain with urination. The physician diagnoses her with a urinary tract infection. Which intrapartum complication is she at increased risk for? A: Dysfunctional labor B: Postterm labor C: Shoulder dystocia D: Preterm labor
Correct: D A: Incorrect. Maternal urinary tract infections have not been shown to be associated with dysfunctional labor. B: Incorrect. Although the exact cause of postterm labor is unknown, urinary tract infection has not been shown to lead to postterm labor. C: Incorrect. Infection has not been linked to shoulder dystocia. D: Correct. Infections of the cervix or urinary tract are the only factor definitively shown to cause preterm labor.
A patient presents with premature rupture of membranes at 34 weeks. Which of the following orders should the nurse question? A. Avoidance of tub baths B. Broad-spectrum antibiotics C. Daily Fetal Movement Counts D. Total Bed Rest
Correct: D Avoidance of tub baths and broad-spectrum antibiotics are two methods for preventing the mother from acquiring an infection, such as chorioamnionitis. Daily fetal movement counts are an effective way for the mother to monitor the status of the fetus, in addition to other fetal assessment methods. While modified bed rest may be ordered, total bed rest can lead to adverse physical effects, such as the formation of thrombus, muscular atrophy, and weakening of the heart and muscles
A nurse on the postpartum unit is assessing a primiparous woman with gas pain, 12 hours after her performed cesarean section. Which observation would be concerning to the nurse? A: The patient places the pillow over her abdomen while coughing. B: The patient states she only passed gas once within the last hour. C: With assistance, the patient walks 5 feet to use the restroom. D: Two empty 12 oz. cans of coke are set at the bedside.
Correct: D Correct. Carbonated beverages should be avoided to minimize the severity of gas pains. (PWC: Typically, gas pains are the worst the second post-op day, not 12 hours after birth.)
A 21 year old nulligravida patient with a history of Marfan's Syndrome comes into a woman's health clinic for her initial examination. During a conversation with the nurse, the patient asks the nurse, "If I have children someday, will they have Marfan's Syndrome just like me?" What would be an appropriate response by the nurse? A. "Marfan's is autosomal dominant; therefore, the baby will have it." B. "This cannot be predicted because this syndrome is not inherited." C. "You shouldn't worry about that yet. You're not even pregnant." D. "There is a 50% chance the child would have Marfan's syndrome."
Correct: D Marfan's syndrome is an autosomal dominant genetic disorder characterized by generalized weakness of the connective tissue. Preconception genetic counseling is recommended to make women aware of the risks of pregnancy with this condition.
A 26 year old primigravida at 38 weeks gestation presents to the emergency room with labor pains. After assessment, the presentation of the fetus is confirmed to be breech. The nurse is placing fetal heart monitors on the patient per protocol. What action by the nurse indicates an understanding of the placement of fetal heart monitors? Placement of the fetal heart monitor: a. Below the umbilicus b. At or above the umbilicus c. In the right lower quadrant d. In the left lower quadrant
Correct:B A. Incorrect. For breech presentation, this placement is not indicated as the best place for fetal heart tones to be heard. B. Correct. The heart tones of fetuses in a breech position are best heard at or above the umbilicus C. Incorrect. This placement is best for ROA fetal presentation. D. Incorrect. This placement is best for LOA fetal presentation.
Which of the following would be cause for increased measuring and recording of a newborn's weight? A) Low Birth Weight Preterm Infant B) Bottle Fed Infant C) Large for gestational age term infant D) Breast fed infant
Rationale A is the correct answer. It can be expected that a term appropriate for gestational age infant would experience a weight loss of 7-10% of birth weight, but a preterm infant can experience a weight loss of up to 15% of the birth weight during the first week of life. Because of this, a preterm infant's weight is carefully monitored during the first week of life and beyond. Breastfeeding is an excellent source of nutrients that an infant needs, and it is actually recommended that preterm infants receive breast milk as it can lead to decreased complications. In cases where breastfeeding is unable to happen, there are commercially available formulas that offer increased nutrients to help supplement and promote growth (Lowdermilk, Perry, Cashion, & Alden, 2012).
A nurse is caring for 4 postpartum patients on the couplet care unit. Which of the following patients would be most at risk for developing a postpartum infection? A) A 28 year old patient 1 day postpartum who has a history of diabetes mellitus B) A 32 year old patient 2 days postpartum with a WBC of 15,000 C) A 23 year old patient 12 hours postpartum with a temperature of 100.4F D) A 27 year old patient 48 hours postpartum who was in labor for 6 hours.
Rationale: A: Correct; A history of diabetes mellitus predisposes a woman to develop a postpartum infection (Lowdermilk, Perry, Cashion, and Alden, p 813). B: Incorrect; a slightly elevated WBC is considered normal in a postpartum woman (up to 20,000-25,000) (White-Corey, 2015). C: Incorrect; a slightly elevated temperature such as 100.4 within the first 24 hours following labor/birth is considered normal (Lowdermilk, Perry, Cashion, and Alden, p 812) D: Incorrect; while a prolonged labor can put a woman at risk for a postpartum infection, a labor time of 6 hours is not considered prolonged (Lowdermilk, Perry, Cashion, and Alden, p 813)
The nurse educator of the labor and delivery unit is holding an in-service on vaginal birth after cesarean (VBAC) to new graduate nurses. Which statement in her presentation is incorrect and should be questioned by the graduate nurses? A. Benefits to VBAC include shorter hospital stay and less blood loss. B. The overall VBAC success rate is approximately 70% to 80%. C. A risk associated with VBAC includes uterine rupture. D. Nurses should discourage all women from pursuing a VBAC.
Rationale: Answer D is correct. The nurse should give information about VBAC to the woman and encourage her to choose it as an alternative to repeat cesarean birth, as long as no contraindications exist (p. 815). Benefits of VBAC include a shorter maternal hospital say, less blood loss, fewer infections and fewer thromboembolic events. Risks associated with VBAC include uterine rupture, hysterectomy, operative injury, and neonatal morbidity. The overall VBAC success rate is approximately 70% to 80%. Therefore, A, B, and C are correct statements by the nurse educator.
A 34 y/o postpartum woman complains of unilateral calf pain, swelling, and tenderness. After a brief physical examination, the nurse identifies a positive Homan's sign and notifies the physician. The patient is diagnosed with superficial venous thrombosis. Which physician order would the nurse question? A: Apply warm, moist heat to the affected site and apply SCDs B: Administer IV heparin therapy for 3 - 5 days or until symptoms resolve C: Inform the patient to take Aspirin 81mg daily for the following month D: Continue oral anticoagulant therapy (warfarin), after discharge for approximately 3 months
Rationale: Correct Answer: C) "Medications containing aspirin are not given to women receiving anticoagulant therapy because aspirin inhibits synthesis of clotting factors and can lead to prolonged clotting time and increased risk of bleeding" (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 833). According to Lowdermilk et al., (2012) all other answer choices are considered appropriate forms of nursing management/interventions (p. 833).
A nurse is caring for a neonate preoperatively for a myelomeningocele. Which major nursing intervention is not warranted for the nurse to perform in this situation? A) Cover the sac with a sterile, moist, non-adherent dressing B) Place the infant in a prone-kneeling position C) Recording of intake and output D) Place a drape over the buttocks and above the lesion
Rationale: Incorrect. The nurse should cover the sac with a sterile, moist, non-adherent dressing, and cared for using sterile technique. Incorrect. The infant should be positioned in prone-kneeling position and knees protected from skin breakdown. Incorrect. The intake and output are recorded to document the number and character of the stools and voids as well as leakage of urine and stool. Correct. The drape should be placed over the buttocks below the lesion to keep the lesion free of meconium or stool.
The nurse is doing a morning assessment on a neonate who has been diagnoses with Fetal Alcohol Syndrome (FAS). Which assessment finding would the nurse consider to be abnormal for a newborn with FAS? A) A short eyelid opening B) Abnormally small head size in relation to body size C) A Simian crease on the hand D) A thin upper lip
Rationale: Incorrect: This is a normal finding for a newborn with FAS. Incorrect: This is a normal finding for a newborn with FAS. This is known as microcephaly. Correct: This would be considered an abnormal finding for a patient with FAS. A simian crease is found by assessing the hand and can be an indication of Down's syndrome. Further diagnostic testing would be necessary to confirm a diagnosis of Down's Syndrome Incorrect: This is a normal finding for a newborn with FAS. (PWC: none are normal. some are expected)
The nurse is providing teaching to a 26 year old primigravida patient who had a vaginal delivery 2 days ago, but has since reported pain when urinating, having to urinate frequently, and urinary urgency. A urinary analysis determined the patient has a urinary tract infection. What statement made by the patient shows she requires more teaching? A. "I will make sure to take my full course of antibiotics as prescribed" B. "I will not drink a lot of water, so I won't have to go to the bathroom often" C. "I will make sure to wipe from front to back after using the bathroom" D. "I will monitor my temperature and appearance of my urine for changes" .
Rationale: A. Incorrect- This statement is true. The patient should be taught to take the full course of antibiotics, even if she is feeling better, to ensure the infection is truly eliminated (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 835). B. Correct- The patient should be educated to increase fluid intake to promote hydration, which is an important component of treatment for urinary tract infections (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 835). C. Incorrect- This statement is true. The patient should be taught ways to prevent future urinary tract infections and this includes topics such as wiping from front to back after toileting (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 835). D. Incorrect- This statement is true. Urinary tract infections are usually treated on an outpatient basis. So, proper patient education is needed about what signs and symptoms to be aware of and when to report them to a physician (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 835)
A nurse is speaking to a recent primiparous mother about the newly diagnosed condition of necrotizing enterocolitis of her preterm newborn. Which statement made by the mother indicates that further teaching is needed? "My baby has this condition because I fed him too much breast milk." "My baby's intestines are not getting proper oxygenation." "My baby may need surgery if his intestines rupture." "My baby's tube feedings will be discontinued now."
Rationale: True. This statement indicates further teaching is needed. A condition associated with the development of NEC is enteral feedings. Breast milk seems to have a protective effect against the development of NEC. Incorrect. Intestinal ischemia occurs as a result of asphyxia/hypoxia or events that cause a redistribution of blood flow away from the GI tract. Incorrect. Surgical resection is performed if perforation or clinical deterioration occurs. For the infant with suspected or confirmed NEC, oral or tube feedings are discontinued to rest the GI tract.
A 27 year old primipara has given birth two hours ago to a healthy baby boy with the placenta intact. She delivered vaginally and has 3rd degree laceration to the perineum. After assessment, the nurse determined that the patient has a boggy fundus and a large amount of lochia rubra with several clots on the peri-pad. Her estimated blood loss at delivery was 500 mL. What is the priority nursing intervention? A: Notify the physician of the findings B: Firmly massage the uterine fundus C: Administer Cytotec 1000 mcg per rectum D: Apply bimanual compression of the uterus
Rationale: ANSWER B A: Notifying the physician is important but is not a first priority B: Massaging the uterine fundus will promote a uterine contraction which will slow or stop the bleeding. "The initial management of excessive postpartum bleeding is a firm massage of the uterine fundus" C: A patient with a 3rd or 4th degree laceration should not be given anything per rectum D: Nurses do not provide bimanual compression to the uterus, obstetricians or nurse-midwifes can do this. (PWC: Regarding answer C, you must also first obtain a physician's order prior to administering any medication. Regarding answer D, there is no "law" against a nurse providing bimanual compression if other interventions are not working and the doctor is not there yet. If it meant saving the patient's life, I would do it.)
The nurse is assessing an infant born 4 hours ago at 38 weeks gestation to a mother with gestational diabetes. She notices that the infant is tremoring, has an exaggerated Moro reflex, is tachypnic, and has been feeding poorly over the last few hours. Which intervention should the nurse implement first? A) Place the baby in the prone position B) Administer IV D10W C) Check the baby's blood glucose level D) Administer a corticosteroid
Rationales Incorrect. This is not an effective intervention for an infant with hypoglycemia. Incorrect. The nurse must have an order from the physician before administering medications. She must first determine if the newborn is hypoglycemic before notifying the physician for orders. Correct. The nurse would first check the blood glucose level to determine if the newborn is experiencing hypoglycemia before administering medications. Incorrect. Corticosteroids are only administered in severe cases of hypoglycemia. The severity of the hypoglycemia cannot be definitively established without checking the blood glucose level.
Upon assessment, the nurse notes that a patient who just underwent spontaneous vaginal delivery is having excessive postpartum bleeding currently estimated at 600mL. Which intervention would be the priority action at this time? A: Bimanual compression of the uterus B: Massage the uterine fundus C: Insert a Foley catheter D: Administer blood products
Rationales: A. Incorrect. Bimanual exam would not be needed at this time (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 805). B. Correct. The initial intervention in management of postpartum bleeding is to massage the uterine fundus to expel clots and promote uterine contractions (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 805). C. Incorrect. Although eliminating bladder distention is a priority it does not come before massaging the fundus (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 805). D. Incorrect. Blood products are not necessary at this time (Lowdermilk, Perry, Cashion, & Alden, 2012, p. 805).