Course Point TTRs B

Which assessment would lead the nurse to believe a postpartal woman is developing a urinary complication? At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. She says she is extremely thirsty. Her perineum is obviously edematous on inspection.

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Postpartal women who void in small amounts may be experiencing bladder overflow from retention. pg. 855

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? bleeding postpartal gestational hypertension infection diabetes

Bleeding Blood pressure should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level. pg. 539

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Feed the baby at least every two or three hours. Apply cold compresses to the breasts. Provide the infant oral nystatin. Dry the nipples following feedings.

Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain. pg. 544

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Avoid massaging the breast area. Avoid frequent breast-feeding. Perform handwashing before breast-feeding. Apply cold compresses to the breast.

Perform handwashing before breast-feeding. As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breast-feeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold, not warm, moist heat to the breast. Gently massaging the affected area of the breast also helps. pg. 852

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth? Avoid use of water-based gel lubricants. Resume intercourse if bright red bleeding stops. Avoid performing pelvic floor exercises. Use oral contraceptives for contraception.

Resume intercourse if bright red bleeding stops. The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptives. pg. 575

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? infection hemorrhage normal involution atony

atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage. pg. 560

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: acutely decreased. acutely increased. slightly decreased. slightly increased.

acutely decreased Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage. pg. 538

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: inspect the perineum for lacerations. increase the flow of an IV. assess and massage the fundus. call the primary care provider or the nurse-midwife.

assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage. pg. 562

The nurse is caring for a child with Down syndrome (trisomy 21). This is an example of which type of inheritance? Mendelian recessive Mendelian dominant chromosome nondisjunction phase 2 atrophy

chromosome nondisjunction Down syndrome occurs when an ovum or sperm cell does not divide evenly, permitting an extra 21st chromosome to cross to a new cell. pg. 353

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? infection dehydration change in the temperature from the birth room fluid volume overload

dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours. pg.. 559

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary overflow postpartum diuresis urinary tract infection trauma to pelvic muscles

postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency. pg. 540

Nurses are expected to know how to use the first genetic test. What is it? the developmental assessment the family history the physical assessment the psychosocial assessment

the family history The family history is considered the first genetic test. It is expected that all nurses will know how to use this genetic tool. The other answers are incorrect because the developmental, physical, and psychosocial assessments are not the first genetic test. pg. 356

A number of inherited diseases can be detected in utero by amniocentesis. Which disease can be detected by this method? diabetes mellitus trisomy 21 phenylketonuria impetigo

trisomy 21 Karyotyping for chromosomal defects can be carried out using amniocentesis. pg. 357

A 33-year-old pregnant client asks the nurse about testing for birth defects that are safe for both her and her fetus. Which test would the nurse state as being safe and noninvasive? CVS amniocentesis ultrasound percutaneous umbilical cord sampling

ultrasound The nurse would state that an ultrasound is a noninvasive test that is completely safe for both mother and child. Amniocentesis, CVS, and percutaneous umbilical cord sampling are invasive tests that are associated with maternal and fetal risk. pg. 345

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? hemoglobin level of 12 g/dL uterine atony thrombophlebitis moderate amount of lochia rubra

uterine atony Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits. pg. 840

At a prenatal checkup with a client at 7 weeks' gestation, the nurse would identify what as a normal finding? Quickening is detected by the mother. Fetal heart sounds are heard. Gender identity is determined with ultrasound. The fetus would have a startle reflex.

Fetal heart sounds are heard. Although the heart is not fully developed, it begins to beat at week 5, and a regular rhythm and can be heard at week 7. Quickening is felt around week 13. Gender identity can be determined at weeks 9 to 12. The startle reflex can be seen around weeks 21 to 24. pg. 340

A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard? "I would suggest that you speak with your primary care provider about this." "Drink plenty of cold fluids before you go to bed." "Be sure to change your pajamas to prevent you from chilling." "I'm not sure why this is occurring since this usually doesn't occur until much later in the postpartum period."

"Be sure to change your pajamas to prevent you from chilling." The nurse should encourage the client to change her pajamas to prevent chilling and reassure the client that it is normal to have postpartal diaphoresis. Drinking cold fluids at night will not prevent postpartum diaphoresis. pg. 541

A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? "I need to assess your fundus now." "It sounded like you had quite a time getting here. Would you like to continue your story?" "You have a beautiful baby, why worry about that now?" "If you plan to breast-feed, you need to calm down."

"It sounded like you had quite a time getting here. Would you like to continue your story?" The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation. pg. 548

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood."

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis. pg. 585

A client who is 15 weeks' gestation is attending prenatal classes and asks the nurse, "What changes in development has my baby made?" Which statements would the nurse include in the response? Select all that apply. "Soft hair covers your baby's head." "Your baby makes sucking motions now with its mouth." "You will be able to detect quickening." "The increase in weight of your baby has stopped now." "Your baby's lungs are ready for life outside the uterus."

"Soft hair covers your baby's head." "Your baby makes sucking motions now with its mouth." "You will be able to detect quickening." During weeks 13 through 16, a fine hair called lanugo develops on the head. The fetus makes active movement, sucking motions are made with the mouth, weight quadruples, and fetal movement (also known as quickening) is detected by mother. Alveoli of the lungs have not developed, and thus lungs are not ready for life outside the womb. pg. 340

The health care provider prescribes 50 mg daily by mouth of clomiphene for a client having fertility problems. The client cannot swallow pills. Available is 200 mg/5 mL elixir. How many milliliters of the medication would the nurse administer? Record your answer using two decimal points.

1.25 The order is for 50 mg. There are 200 mg in 5 mL. Thus, there are 40 mg per mL. The problem is solved by: 50 mg/X ml = 40 mg/1mL X= 1.25 mL

A pregnant client is scheduled to undergo chorionic villi sampling (CVS) to rule out any birth defects. Ideally, when should this testing be completed? 10 to 12 weeks of gestation 7 to 9 weeks of gestation 5 to 6 weeks of gestation 4 to 5 weeks of gestation

10 to 12 weeks of gestation Chorionic villus sampling (CVS) is typically performed between 10 to 12 weeks' gestation. Sometimes it may be offered up to 14 weeks. The test is not conducted before 10 weeks' gestation. pb. 357

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? 500 mL 750 mL 1000 mL 250 mL

1000 mL Postpartum hemorrhage is defined as blood loss of 500 mL or more after a vaginal birth and 1000 ml or more after a cesarean birth. pg. 840

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval? 2 weeks 3 weeks 4 weeks 5 weeks

2 weeks The general rule of thumb is for a woman who had a cesarean birth be seen within 2 weeks after hospital discharge, unless the primary care provider has indicated otherwise or if the client develops signs of infection or has other difficulties. pg. 585

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 100 mL 250 mL 300 mL 500 mL

500 mL Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth. pg. 840

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? A client who had a nonelective cesarean birth A primaparous client who had a vaginal birth A client who had an 8-hour labor A client who conceived following fertility treatments

A client who had a nonelective cesarean birth The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. The other listed factors are not noted risk factors for infection. pg. 852

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first? Contact the primary care provider to report the client's deteriorating mental status. Discuss the client's potential depression with her family members. Ask the client to elaborate on her feelings. Document the conversation.

Ask the client to elaborate on her feelings The client's affect is consistent with postpartum blues, a transient source of sadness experienced during the first week after birth. The nurse should offer support to the client and encourage her to discuss her concerns and feelings. The client's emotional state is normal and contacting the care provider is not indicated. Discussing the client's feelings with family members is a violation of confidentiality and is not an appropriate action. Documenting the interaction is indicated but should take place after the encounter is completed. pg. 858

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response? Ask the client why she does not want to go home. Inform the primary care provider that the client does not want to go home. Tell the client that she must go home as per hospital policy. Ask the client if she has any support in the home.

Ask the client why she does not want to go home. It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. Open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address concerns appropriately. Asking about supports at home implies that the nurse has made assumptions about why the client may not want to go home. Informing the care provider or telling the client that discharge is hospital policy is not appropriate at this time because the nurse has not addressed the underlying reason for the client's comment. The client may have safety-related concerns, undisclosed fears, or a need for increased support before discharge. It is imperative that the nurse not make assumptions but further explore concerns. pg. 549

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? Attachment, lochia color, complete blood cell count Blood pressure, pulse, reports of dizziness Degree of responsiveness, respiratory rate, fundus location Height, level of orientation, support systems

Blood pressure, pulse, reports of dizziness Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more. pg. 848

Which body system is most affected throughout the embryonic and fetal period by teratogens? Gastrointestinal system Genitourinary system Central nervous system Musculoskeletal system

Central nervous system Whether the teratogen is ingested, injected, occurs through an infectious agent or is environmental, the CNS and brain are the body systems that are most seriously affected during this period.

A 38-year-old client presents to the clinic desiring to get pregnant. She reports she had a tubal ligation in her early 20s after two babies and a divorce. After learning that the client recently underwent a reversal of the tubal ligation, the nurse will warn the client of which potential risk? Ectopic pregnancy Downs syndrome Twins Exposure to teratogens

Ectopic pregnancy Tubal ligation reversal is a difficult procedure and can place the woman at higher risk for ectopic pregnancy. She needs to be aware of the possibility. Down syndrome, multiple births, and exposure to teratogens are all issues that have nothing to do with reversal of tubal ligation. These are issues that any pregnant female should be made aware.

Fetal circulation differs from the circulatory path of the newborn infant. In utero the fetus has a hole connecting the right and left atria of the heart. This allows oxygenated blood to quickly pass to the major organs of the body. What is this hole called? Foramen venosus Foramen magnum Foramen arteriosus Foramen ovale

Foramen ovale The foramen ovale is a hole that connects the right and left atria so the majority of oxygenated blood can quickly pass into the left side of the fetal heart, go to the brain and move to the rest of the fetal body. pg. 343

A nurse is assessing a postpartum client. Which measure is appropriate? Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. Instruct the client to empty her bladder before the examination. Wear sterile gloves when assessing the pad and perineum. Perform the examination as quickly as possible.

Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth. pg. 571

A couple wants to start a family. They are concerned that their child will be at risk for cystic fibrosis because they each have a cousin with cystic fibrosis. They are seeing a nurse practitioner for preconceptual counseling. What would the nurse practitioner tell them about cystic fibrosis? It is an autosomal dominant disorder. It is passed by mitochondrial inheritance. It is an X-linked inherited disorder. It is an autosomal recessive disorder.

It is an autosomal recessive disorder. Cystic fibrosis is autosomal recessive. Nurses also consider other issues when assessing the risk for genetic conditions in couples and families. For example, when obtaining a preconception or prenatal family history, the nurse asks if the prospective parents have common ancestors. This is important to know because people who are related have more genes in common than those who are unrelated, thus increasing their chance for having children with autosomal recessive inherited condition such as cystic fibrosis. Mitochondrial inheritance occurs with defects in energy conversion and affects the nervous system, kidney, muscle, and liver. X-linked inheritance, which has been inherited from a mutant allele of the mother, affects males. Autosomal dominant is an X-linked dominant genetic disease. pg. 350

An expectant mother asks the nurse which of her antibodies from previous immunizations would be passed to her fetus during pregnancy. Which response by the nurse would be correct? Measles antibodies will cross the placenta to protect the fetus. If the mother was immunized within the last year for varicella, the immunity will pass to the fetus. Since the flu vaccine is passed easily, the fetus will not need a flu shot for 2 years. Cytomegalovirus is one of the first passive antibodies to cross the placenta.

Measles antibodies will cross the placenta to protect the fetus. Some maternal antibodies passively cross the placenta in pregnancy. These include measles, diphtheria and smallpox. Those not crossing are rubella, cytomegalovirus, and varicella. Annual flu shots do not cross the placenta either.

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? Recommend a moisturizing soap to clean the nipples. Encourage use of breast pads with plastic liners. Offer suggestions based on observation to correct positioning or latching. Fasten nursing bra flaps immediately after feeding.

Offer suggestions based on observation to correct positioning or latching. The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry. pg. 577

A pregnant client and her husband have had a session with a genetic specialist. What is the role of the nurse after the client has seen a specialist? Identify the best decision to be taken for the client. Refer the client to another specialist for a second opinion. Review what has been discussed with the specialist. Refer the client for further diagnostic and screening tests.

Review what has been discussed with the specialist. After the client has seen the specialist, the nurse should review what the specialist has discussed with the family and clarify any doubts the couple may have. The nurse should never make the decision for the client but rather should present all the relevant information and aid the couple in making an informed decision. There is no need for the nurse to refer the client to another specialist or for further diagnostic and screening tests unless instructed to do so by the specialist. pg. 356

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? Showing increased confidence when caring for the newborn Talking about her labor experience to others around her Pointing out specific features in the newborn Having feelings of grief or guilt

Showing increased confidence when caring for the newborn Independence with self-care is an important aspect of the taking-hold phase. During the letting-go phase, the woman assumes responsibility and care for the newborn with increased confidence. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies. pg. 549

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? The most common pathogen is group A beta-hemolytic streptococci. A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breastfeeding client. Symptoms include fever, chills, malaise, and localized breast tenderness.

Symptoms include fever, chills, malaise, and localized breast tenderness. Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally. pg. 855

The primary care provider has prescribed a karyotype for a newborn. The mother questions what the type of information that will be provided by the test. What information should be included in the nurse's response? The karyotype will provide information about the severity of your baby's condition. A karyotype is useful in determining the potential complications the baby may face as a result of its condition. The karyotype will assess the baby's chromosomal makeup. The karyotype will determine the treatment needed for the infant.

The karyotype will assess the baby's chromosomal makeup. The pictorial analysis of the number, form, and size of an individual's chromosomes is referred to as a karyotype. This analysis commonly uses white blood cells and fetal cells in amniotic fluid. The chromosomes are numbered from the largest to the smallest, 1 to 22, and the sex chromosomes are designated by the letter X or the letter Y. The severity and related complications of a disorder are not determined by the karyotype. Condition management is not determined by the karyotype. pg. 349

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change? increased progesterone levels decreased intra-abdominal pressure decreased bladder pressure use of anesthesia during birth

decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal. pg. 541

x The nurse is assisting a young mother who has decided not to breastfeed her infant. The nurse should make which suggestions to the client to ease discomfort and prevent breast engorgement? Select all that apply. Wear tight supportive bra 24 hours each day. Apply ice to the breast for approximately 15 to 20 minutes every other hour. Avoid sexual stimulation. Pump her breasts once a day only. Take a hot shower.

Wear tight supportive bra 24 hours each day. Apply ice to the breast for approximately 15 to 20 minutes every other hour. Avoid sexual stimulation. For women who are not breastfeeding, some current relief measures include wearing a tight, supportive bra 24 hours daily; applying ice to her breasts for approximately 15 to 20 minutes every other hour; avoiding sexual stimulation; and not stimulating the breasts by squeezing or manually expressing milk from the nipples. In addition, avoiding exposing the breasts to warmth will help relieve breast engorgement. pg. 545

The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartal blues? an 18-year-old mother who is currently holding her baby and looking face-to-face at the baby without saying a word a 29-year-old mother who has lots of family visiting and offering to help her with meals and cleaning for the next few months a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding a 38-year-old G1 P1 who is constantly holding the baby and touching the baby's hands and fingers

a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding During the postpartal period many women experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The teenage mom is holding the baby in en face position, which is normal. The 29-year-old woman has a supportive, close family and there is no indication she is experiencing postpartal blues. The 38-year old-mother is in a normal phase after birth and is exploring the infant's body, a part of the taking-in phase that occurs 1 to 3 days after birth.

The maternal serum alpha fetoprotein blood test is performed on pregnant women to screen for: fetal neural tube defects. maternal diabetes. maternal bladder infections. sexually transmitted infections.

fetal neural tube defects. The maternal serum alpha fetoprotein blood test is performed on pregnant women to screen for fetal neural tube defects. The 1-hour random glucose tolerance test is used to screen for diabetes in pregnant women, and a urine test is used to screen for bladder infections. Different tests are used to screen for sexually transmitted infections.

Genetics-related health care is basic to the holistic practice of nursing. What should nursing practice in genetics include? identifying genetic markers gathering relevant family and medical history information providing advice on termination of pregnancy discouraging females to conceive after the age of 40 years

gathering relevant family and medical history information The nurse's role in genetic counseling is to provide information, collect relevant data, offer support, and coordinate resources. The other answers are incorrect because the nurse does not provide advice or influence the client to make choices. The nurse also does not identify genetic markers. pg. 356

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? generally within 3 to 6 weeks whenever the couple wishes generally after 12 weeks usually within a couple weeks

generally within 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum. pg. 575

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition? hemorrhoids hemorrhage thromboembolism cervical laceration

hemorrhage The nurse should monitor the pulse and blood pressure frequently in the first 24 hours postpartum because the client is at greatest risk of hemorrhage. Hemorrhoids cause discomfort and contribute to constipation; this does not call for monitoring of pulse and blood pressure frequently. Increased coagulability causes increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-assisted births pose an increased risk for cervical laceration. None of these conditions require monitoring of pulse and blood pressure. pg. 539

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? cracking of the nipple improper positioning of infant inadequate secretion of prolactin inability of infant to empty breasts

inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk. pg. 544

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia? lochia rubra lochia serosa lochia normalia lochia alba

lochia rubra Lochia rubra is red; it lasts for the first few days of the postpartal period. pg. 537

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: the client will show no signs of infection. discuss methods that the woman will use to prevent infection. list signs of infection that she will report to her health care provider. maintain previous household routines to prevent infection.

maintain previous household routines to prevent infection. The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman. pg. 584

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? normal findings in breastfeeding mothers an improperly positioned baby during feedings mastitis too much milk being retained

mastitis Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly. pg. 560

An 18-year-old pregnant woman asks the nurse why she has to have a routine alpha-fetoprotein serum level drawn. The nurse explains that this: is a screening test for placental function. tests the ability of her heart to accommodate the pregnancy. may reveal chromosomal abnormalities. measures the fetal liver function.

may reveal chromosomal abnormalities. An alpha-fetoprotein analysis is a cost-effective screening test to detect chromosomal and open-body-cavity disorders. pg. 357

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount? scant light moderate heavy

moderate Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour. pg. 562

A nurse is conducting a in-service education program for a group of nurses working in the postpartum unit about postpartal infection. The nurse determines that the teaching was successful when the group identifies which factor as contributing to the risk for infection postpartally? placenta removed via manual extraction labor of 12 hours hemoglobin of 11.5 mg/dL multiparity

placenta removed via manual extraction Manual removal of the placenta, a labor longer than 24 hours, a hemoglobin less than 10.5 mg/dL, and multiparity, such as more than three births closely spaced together, would place the woman at risk for postpartum infection. pg. 559

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching? moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding. pg. 537

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? one fingerbreadth above the umbilicus one fingerbreadth below the umbilicus at the level of the umbilicus below the symphysis pubis

one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis. pg. 560

A nurse is providing care to a woman who has just found out that she is pregnant. The nurse is describing the events that have occurred and the structures that are forming. When describing the trophoblast to the client, the nurse would explain that this structure forms: fetal membrane placenta zygote morula.

placenta. The trophoblast forms the placenta and chorion. The blastocyste forms the embryo and amnion. The zygote is formed from the union of the sperm and ovum. The morula is a mass of 16 cells that develop as cleavage cell division continues after fertilization. pg. 338

When palpating for fundal height on a postpartal woman, which technique is preferable? placing one hand at the base of the uterus, one on the fundus placing one hand on the fundus, one on the perineum resting both hands on the fundus palpating the fundus with only fingertip pressure

placing one hand at the base of the uterus, one on the fundus Explanation: Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation. pg. 560

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? policies that discourage unwrapping and exploring the infant policies that allow rooming the infant and mother together policies that allow visitors policies that allow flexibility for cultural differences

policies that discourage unwrapping and exploring the infant Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur. pg. 566

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production? prolactin estrogen oxytocin progesterone

prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum. pg. 542

Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis? edema in perineal area redness in lower legs diaphoresis increased lochia

redness in lower legs The nurse should identify redness, swelling, or warmth in the lower legs as early signs of thrombophlebitis. Edema in the perineal area usually accompanies an episiotomy. Diaphoresis is a normal finding in the immediate postpartum period. Increased lochia could be due to uterine atony. pg. 540

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? taking-in phase taking-hold phase letting-go phase attachment phase

taking-in phase During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant. pg. 548

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? venous duplex ultrasound of the right leg transthoracic echocardiogram venogram of the right leg noninvasive arterial studies of the right leg

venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency. pg. 564

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. women on antithyroid medications women on antineoplastic medications women using street drugs women with more than one infant women who had difficulties with breastfeeding in the past

women on antithyroid medications women on antineoplastic medications women using street drugs While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules. pg. 577