CoursePoint

The above nurse's note was documented in the client's record by the labor room nurse. In which position was the client born?

With the occiput facing the right anterior quadrant of the pelvis

The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location?

at the level of the umbilicus

The nurse has just administered morphine 2 mg IV to a laboring client. Which change in the fetal heart rate pattern would the nurse prioritize? late decelerations early decelerations decreased variability increased variability

decreased variability

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

increased white blood cell count

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 alba lochia rubra lochia normalia lochia serosa

lochia rubra Explanation: Lochia rubra is red; it lasts for the first few days of the postpartum period.

The nurse is assessing a client for rupture of membranes. Which findings would confirm the presence of ruptured membranes? Select all that apply.

Nitrazine paper turns blue. Ferning is present. A pool of fluid is visible in the vagina.

A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?

The client reports back pain, and the cervix is effacing and dilating.

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?

0

A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? 4 to 6 ounces 1 to 2 ounces 6 to 8 ounces 2 to 4 ounces

2 to 4 ounces Explanation: Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek, 2010). Therefore, a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.

A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?

Administer pain medications. Explanation: "Afterpains" should be expected in postpartum clients. These are commonly treated with pain analgesics. The client should not stop breastfeeding. Assessing vital signs and helping the client to void are not the priority interventions for this client.

A new mother delivered 1 week ago and is tearful, anxious, sad, and has no appetite. She is diagnosed with postpartum blues. What factors contribute to this problem? Select all that apply. Lack of activity Hormonal changes Fatigue Discomfort Disrupted sleep patterns

Hormonal changes Fatigue Discomfort Disrupted sleep patterns Explanation: Postpartum blues occur in 40% to 80% of postpartum women. The exact cause is unknown but there are certain factors that do contribute to this occurring. These include hormonal changes, disrupted sleeping patterns from getting up with the newborn, discomfort from delivery, and fatigue. Too much activity causes postpartum blues, not lack of activity.

The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply. Gently palpate for any hematomas. Palpate the episiotomy for pain. Place the patient in Trendelenburg position for inspection. Note any hemorrhoids. Inspect the episiotomy for sutures and to ensure that the edges are approximated.

Inspect the episiotomy for sutures and to ensure that the edges are approximated. Note any hemorrhoids. Gently palpate for any hematomas. Explanation: The client is placed in the Sims position, not Trendelenburg position, for inspection. The nurse will then use a light to look at the perineum, noting any hemorrhoids, inspecting the episiotomy (if present) and palpating for any hematomas. The episiotomy is not palpated due to the pain associated with it, and the nurse can visually inspect it.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? 6.5 5.0 6.0 5.5

6.5 Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.

Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH? 7.4 7.0 7.2 6.8

7.2 Umbilical cord blood acid-base analysis is considered the most reliable indication of fetal oxygenation and acid-base condition at birth. The normal mean pH value range is 7.2 to 7.3.

Which occurs as a result of contraction decrement? Select all that apply.

Blood flow to the fetus improves. Fetal heart rate should return to baseline.

A postpartum woman tells the home care nurse, "My hemorrhoids are really uncomfortable. Is there anything I can do?" Which suggestion(s) by the nurse would be appropriate? Select all that apply. "You should pour cold water over the area with your peribottle." "Witch hazel pads can have a cooling effect." "You might think anesthetic sprays help but they do not." "Applying ice to the area can help." "I will show you how to use a sitz bath."

"Applying ice to the area can help." "Witch hazel pads can have a cooling effect." "I will show you how to use a sitz bath." Explanation: The presence of swollen hemorrhoids may heighten discomfort in the perineum. Local comfort measures such as ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths can relieve pain.

The nurse is caring for a nullipara client at 40 weeks' gestation. After assessing the client, the health care provider states that the fetus is at a -4 station. Which statement by the client requires clarification by the nurse?

"The health care provider states my labor is imminent."

A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? "You have your daddy's eyes." "He looks like a frog to me." "He seems to sleep a lot." "Where did you get all that hair?"

"He looks like a frog to me." Explanation: Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.

A nurse is teaching a woman in her third trimester about Braxton Hicks contractions. When describing these contractions, which information would the nurse likely include? Select all that apply.

"They usually feel like a tightening across the top of your uterus." "They often spread downward before they go away." "They go away when you walk around or change position."

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching? "You have no trouble walking around and using the bathroom after you receive the epidural." "Epidural anesthesia is more effective than opioid analgesia in providing pain relief." "You can continuously receive epidural anesthesia until you have the baby, and even afterward if you need it." "If you end up having a cesarean, the epidural can be used for anesthesia during surgery."

"You have no trouble walking around and using the bathroom after you receive the epidural." Epidural anesthesia impairs mobility; most clients are placed on bed rest after epidural anesthesia is given. Urinary catheterization is frequently required.

The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is:

1 cm above the ischial spines

During the fourth stage of labor, which mother typically experiences the strongest afterpains?

A multipara who is breast-feeding

Rho(D) immune globulin is administered to which clients? Select all that apply. An Rh-negative woman following an ectopic pregnancy An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday A client who is Rh-positive and gave birth to a 7-pound baby A newborn with type O-negative blood and a negative Coombs test A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood

An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday An Rh-negative woman following an ectopic pregnancy A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood Explanation: Rho(D) immune globulin is never given to an individual with Rh positive blood, and it is never given to the neonate following birth. Rho(D) immune globulin is given to women with Rh negative blood following an ectopic pregnancy, a spontaneous abortion (miscarriage), and the birth of an Rh positive neonate.

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? Encourage the woman to void. Offer warm blankets. Offer a warm sitz bath. Apply an ice pack to the site.

Apply an ice pack to the site. Explanation: An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

A postpartum woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartum? Take her temperature every 4 hours. Palpate her feet for tingling or numbness. Assess for calf redness and edema. Ask her if she feels any warmth in her legs.

Assess for calf redness and edema. Explanation: Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply. Breasts are non-painful One reddened area on the left breast 3 cm in size. Breasts feel slightly firm. Nipples have several cracks on both breasts. Flattened nipple on the right breast

Breasts feel slightly firm. Flattened nipple on the right breast Breasts are non-painful Explanation: Normal findings for a breast exam in a Day 2 postpartum mother should include non-painful breasts, slight engorgement indicative of the milk coming in, and nipples that are either erect or can be drawn out. Reddened areas and cracked nipples are abnormal findings.

The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best?

Continue to monitor the progress of labor.

The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which phase?

increment

The nurse is caring for a client experiencing pruritus secondary to opioid medication administration during labor. When reviewing the medication administration record, which medication would the nurse offer the client? Naloxone Nalbuphine Diphenhydramine Meperidine

Diphenhydramine Diphenhydramine is an antihistamine which would be helpful to the client experiencing pruritus as a side effect of opioid medication administration. Meperidine is another opioid analgesic. Both naloxone and nalbuphine are opioid antagonists.

When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 beats/min? Ask the client what she has had to eat today. Advise that the client not get out of bed until the nurse returns with assistance. Compare the pulse rate with her pulse rate on the first prenatal care visit. Do nothing, this is normal.

Do nothing, this is normal. Explanation: During pregnancy, the distended uterus obstructs the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. Increased stroke volume reduces the pulse rate to between 50 and 70 beats per minute. The nurse should be certain to compare a woman's pulse rate with the slower range expected in the postpartum period, not with the normal pulse rate in the general population. Pulse usually stabilizes to prepregnancy levels within 10 days.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take? Contact the primary care provider, as it is a first sign of postpartum eclampsia. Document the finding, as it is a normal finding at this time. Obtain a prescription for a CBC, as it suggests postpartum anemia. Contact the primary care provider, as it indicates early DIC.

Document the finding, as it is a normal finding at this time. Explanation: Pulse rates of 60 to 80 beats per minute at rest are normal during the first week after birth. This pulse rate is called puerperal bradycardia.

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply. Edema Discharge Slight bruising Bleeding Redness

Edema Slight bruising Explanation: During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness, bleeding or discharge.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? Change the linen saver pad. Check the fetal heart rate. Perform a vaginal exam. Notify the primary care provider immediately.

FHR When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified

What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply. White blood cell count of 28,000/mm3 Temperature of 101.8°F (38.8°C) Lochia rubra Episiotomy appears edematous Fundal height level of one fingerbreadth above the umbilicus

Fundal height level of one fingerbreadth above the umbilicus Temperature of 101.8°F (38.8°C)The uterine fundus should be one fingerbreadth below, not above, the umbilicus. Maternal temperature does increase slightly after delivery but 38.8°C (101.8°F) is too high and the doctor needs to be made aware of it. All other findings are normal.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm. Explanation: The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

Which is the most important nursing assessment of the mother during the fourth stage of labor?

Hemorrhage

A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone? urinating immediately when the urge is felt abdominal crunches Kegel exercises sitz baths

Kegel exercises Explanation: The nurse should recommend that the client practice Kegel exercises to improve pelvic floor tone, strengthen the perineal muscles, and promote healing. Sitz baths are useful in promoting local comfort in a client who had an episiotomy during the birth. Abdominal crunches would not be advised during the initial postpartum period and would not help tone the pelvic floor as much as Kegel exercises.

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer? On the uterine fundus At the level of the umbilicus On the right side of the abdomen Midline but low on the abdomen

On the uterine fundus The nurse is correct to place the tocodynamometer on the fundus with the sensor facing downward and then strap it securely to the abdomen.

Which interventions would the nurse take to reduce the incidence of infection in a postpartum woman? Select all that apply. Wash her hands before and after caring for the client. Encourage intake of fluids following delivery and after discharge. Teach proper positioning of the infant for breastfeeding. Recommend that the mother change her peripads every 12 hours. Have the mother maintain a low activity level to allow the perineum to heal.

Teach proper positioning of the infant for breastfeeding. Encourage intake of fluids following delivery and after discharge. Wash her hands before and after caring for the client. Explanation: To reduce the incidence of postpartum infection, the nurse would always wash her hands before and after caring for the client or her infant. The nurse should also recommend adequate fluid intake to encourage urination and prevent urinary retention, which can lead to a UTI. By teaching proper positioning of the infant for breastfeeding, the frequency of cracked nipples is reduced and cracked nipples can cause mastitis. Peripads are changed more frequently than every 12 hours and perineal care is provided. Early ambulation, rather than little activity, is recommended to strengthen the mother's immune system.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?

The client's cervix is fully dilated.

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?

Third

A woman delivered her infant 24 hours ago by cesarean section. Which assessment findings should be reported to the assigned nurse? Select all that apply. Uterus feels boggy. The client reports breakthrough pain level of 7-8. The client's abdomen is mildly distended and bowel sounds are hypoactive. Bleeding is noted on the abdominal dressing 2 x 5 cm in size. Fundal height is one fingerbreadth below the umbilicus.

Uterus feels boggy. The client reports breakthrough pain level of 7-8.

The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from: developing AB antigens in her blood. developing Rh sensitivity. becoming Rh positive. becoming pregnant with an Rh-positive fetus.

developing Rh sensitivity. Explanation: The woman who is Rh-negative and whose infant is Rh-positive should be given Rho(D) immune globulin within 72 hours after birth to prevent sensitization.

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely? nausea lactation blood loss diuresis

diuresis Explanation: Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in the first postpartum week does not cause major weight loss.

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? bromocriptine methylergonovine ferrous sulfate docusate

docusate Explanation: A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

A nurse is conducting a class for a group of nurses who are newly hired for the labor and birth unit. After teaching the group about fetal heart rate patterns, the nurse determines the need for additional teaching when the group identifies which finding as indicating normal fetal acid-base status? Select all that apply. moderate baseline variability fetal bradycardia absence of late decelerations sinusoidal pattern recurrent variable decelerations

fetal bradycardia sinusoidal pattern recurrent variable decelerations Predictors of normal fetal acid-base status include a baseline rate between 110 and 160 bpm, moderate baseline variability, and absences of later or variable decelerations. Sinusoidal pattern, recurrent variable decelerations, and fetal bradycardia are predictive of abnormal fetal acid-base status.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? fetal baseline rate increasing at least 5 mm Hg with contractions variable decelerations, too unpredictable to count fetal heart rate declining late with contractions and remaining depressed a shallow deceleration occurring with the beginning of contractions

fetal heart rate declining late with contractions and remaining depressed Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel? fundus 4 cm above symphysis pubis and firm fundus height 4 cm below umbilicus and midline fundus two fingerbreadths below umbilicus and firm fundus two fingerbreadths above symphysis pubis and hard

fundus two fingerbreadths below umbilicus and firm Explanation: A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.

A nurse is preparing a presentation about changes in the various body systems during the postpartum period and their effects for a group of new mothers. The nurse explains which event as influencing a postpartum woman's ability to void? Select all that apply. decreased bladder tone from regional anesthesia generalized swelling of the perineum use of oxytocin to augment labor need for an episiotomy use of an opioid anesthetic during labor

generalized swelling of the perineum decreased bladder tone from regional anesthesia use of oxytocin to augment labor

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication? increased lochia drainage fluid volume overload ruptured bladder permanent urinary incontinence

increased lochia drainage Explanation: If the bladder is full in a postpartum mother, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. The other options do not happen if a woman has a distended bladder.

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply. hemoglobin level 10 mg/dL rupture of membranes for 16 hours labor of 12 hours history of diabetes placenta requiring manual extraction

history of diabetes hemoglobin level 10 mg/dL placenta requiring manual extraction Explanation: Risk factors for postpartum infection include history of diabetes, labor over 24 hours, hemoglobin less than 10.5 mg/dL, prolonged rupture of membranes (more than 24 hours), and manual extraction of the placenta.

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason? alleviate perineal pain improve pelvic floor tone reduce lochia promote uterine involution

improve pelvic floor tone Explanation: Pelvic floor muscle training or Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

Prior to discharge is an appropriate time to evaluate the client's status for preventative measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh negative mother? ANA CBC with differential indirect Coombs' test titer screen

indirect Coombs' test Explanation: The indirect Coombs' test is an antibody screen that will indicate whether or not the woman has been sensitized to the Rh positive blood of her infant. A positive result indicates the sensitization has occurred and this can cause complications for future pregnancies. A CBC with differential provides a count of the various blood cells. The ANA and titer screen both analyze the blood for various antibodies that might be present in the blood. They can be used to evaluate for immunization and autoimmune disorders.

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: about the same as after a vaginal birth. saturated with clots and mucus. less than after a vaginal birth. greater than after a vaginal birth.

less than after a vaginal birth Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput

The five "Ps" of labor are:

passageway, passenger, position, powers, psych.

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which action would the nurse include in the discussion as possible strategies for the new mothers to do? Select all that apply. performing Kegel exercises starting jogging avoiding smoking losing weight if obese increasing fluid intake

performing Kegel exercises avoiding smoking losing weight if obese Explanation: Postpartum women should consider low-impact activities such as walking, biking, swimming, or low-impact aerobics as they resume physical activity. They should also consider a regular program of Kegel exercises; losing weight, if necessary; avoid smoking; limiting intake of alcohol and caffeinated beverages; and adjusting the fluid intake to produce a 24-hourly output of 1,000 mL to 2,000 mL.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? labor less than 3 hours multiparity hemoglobin of 11.5 mg/dl (115 g/L) placenta removed via manual extraction

placenta removed via manual extraction Explanation: Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/d (105 g/L). Precipitous labor of less than 3 hours and multiparty of more than three births closely spaced place a woman at risk for postpartum hemorrhage.

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

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.

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: normal. a possible infection. meconium passage. transient fetal hypoxia.

possible infection Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy (a disposable plastic hook [Amnihook] is used to perforate the amniotic sac). Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation

When assessing a postpartum woman, the nurse would find which factor to be most significant in identifying possible postpartum hemorrhage? hematocrit blood pressure cardiac output pulse rate

pulse rate Explanation: Tachycardia in the postpartum woman warrants further investigation. Typically, the postpartum woman is bradycardic for the first two weeks. In most instances of postpartum hemorrhage, blood pressure, and cardiac output remain increased because of a compensatory increase in heart rate. Red blood cell production ceases early in the puerperium, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?

restoration of blood flow to uterus and placenta

Which factor might result in a decreased supply of breast milk in a postpartum client? frequent feedings maternal diet high in vitamin C supplemental feedings with formula an alcoholic drink

supplemental feedings with formula Explanation: Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.

A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis?

sutures

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area? superficial structures above the muscle through the anal sphincter muscle through the perineal muscles through the anterior rectal wall

through the anal sphincter muscle Explanation: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? "Call your healthcare provider if you saturate a peri-pad in less than 4 hours." "You should be seen by your healthcare provider if you have blurred vision." Notify the healthcare provider if your temperature is greater than 99° F (37.2° C)." "Follow up with your healthcare provider within 3 weeks of being discharged."

"You should be seen by your healthcare provider if you have blurred vision." Explanation: The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply. Take prescribed antibiotics until all prescribed doses are completed. Continue breastfeeding on the left side, if the infant is willing to latch on. Use a bottle to feed the infant until the pain and tenderness subside. Until antibiotics are completed, pump the left breast and dispose of the milk. If infant refuses to feed, pump the breast to maintain flow.

Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow. Explanation: An infection of the breast during lactation is termed mastitis. Mastitis can interfere with lactation, and sometimes an infant will refuse to nurse on the affected side. The women's medical provider must be notified to initiate antibiotic treatment. Mothers should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the mother to pump her breasts to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a mother is being treated for mastitis; there is no reason to provide alternative feeding methods or to wean because of maternal mastitis.

An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply. What was the birth weight of the infant? Has the mother experienced any miscarriages or abortions? Has the mother ever been sensitized to Rh-positive blood? Has she delivered by cesarean section or vaginally? Has the mother had any previous pregnancies?

Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? Has the mother experienced any miscarriages or abortions? Explanation: An Rh-negative mother must be interviewed prior to administration of Rho (D) immune globulin to ensure that she is a candidate for the medication. Pertinent questions are whether she has been previously exposed to Rh-positive blood prior to this pregnancy, which could have occurred from a previous pregnancy, abortion or ectopic pregnancy. The type of delivery and the newborn's weight are not relevant.

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do? Have the client sit dangling her legs off the side of the bed for 5 minutes. Assist the client to the bathroom. Ask the client to lie back down and get her a bedpan. Suggest catheterizing her this time to prevent the possibility of fainting.

Have the client sit dangling her legs off the side of the bed for 5 minutes. Explanation: The first time a woman gets up following delivery, it is recommended that she sit up on the side of the bed, dangling her legs for 5 minutes to prevent postural hypotension and lightheadedness. If the woman then feels fine, the nurse will accompany her to the bathroom and back to bed.

A nurse is caring for the client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. Which should the nurse do next? Have the client stop breastfeeding. Tell the client to take an NSAID orally. Ask how often the client is breastfeeding. Instruct the client to take a warm shower.

Tell the client to take an NSAID orally. The nurse should explain to the client that the afterpains are due to oxytocin released by the sucking reflex, which strengthens uterine contractions. An NSAID such as ibuprofen will decrease the discomfort from the afterpains. The client should not discontinue breastfeeding as this could decrease her milk supply. A warm shower may help relax the client; however, the NSAID would be more appropriate at this time.

A nurse is caring for the client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. Which should the nurse do next? Have the client stop breastfeeding. Tell the client to take an NSAID orally. Ask how often the client is breastfeeding. Instruct the client to take a warm shower.

Tell the client to take an NSAID orally. Explanation: The nurse should explain to the client that the afterpains are due to oxytocin released by the sucking reflex, which strengthens uterine contractions. An NSAID such as ibuprofen will decrease the discomfort from the afterpains. The client should not discontinue breastfeeding as this could decrease her milk supply. A warm shower may help relax the client; however, the NSAID would be more appropriate at this time.

The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction? Temp: 97.0° F (36.1° C), HR 80, RR 20, BP 120/72 Temp: 100.2° F (38° C), HR 65, RR 22, BP 130/78 Temp: 99.4° F (37.4° C), HR 90, RR 18, BP 112/67 Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85

Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85 Explanation: Postpartum women may have an elevated temp to 100.4° F (38° C) for 24 hours after birth; they may also have decreased pulse a few weeks after birth. The elevated BP of 150/85 is a concern, as a postpartum woman is still at risk of developing preeclampsia even after birth. The other choices are within normal limits.

Which client should the postpartum nurse assess first after receiving shift report? The 12-hour postpartum client who has a temperature of 100.4° F (38° C). The 1-day postpartum client who has a respiratory rate of 20 breaths/minute. The 2-day postpartum client who has a blood pressure of 138/90 mm Hg. The 3-day postpartum client who has a pulse of 50 bpm.

The 2-day postpartum client who has a blood pressure of 138/90 mm Hg. Explanation: The postpartum client with a blood pressure of 138/90 mm Hg is showing signs of hypertension and should be seen first to assess for preeclampsia. Preeclampsia can occur during the postpartum period. A pulse rate of 50 bpm and a respiratory rate of 20 breaths/minute are within the normal range. A fever of 100.4° F (38° C) or less during the first 24 hours postpartum is common.

When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? expert medical care for the labor and birth grandparent involvement in infant care after birth early parent-infant contact following birth good nutrition and prenatal care during pregnancy

early parent-infant contact following birth Explanation: Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?

increased risk of infection

During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention? moist cloths alcohol wipes baby wipes peribottle and warm water

peribottle and warm water Explanation: Local comfort measures for the perineum after an episiotomy or laceration include ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths.

A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply. resumption of sexual intercourse about two weeks after birth possibility of increased breast sensitivity during sexual activity use of a water-based lubricant to ease vaginal discomfort possible experience of fluctuations in sexual interest use of combined hormonal contraceptives for the first three weeks

possible experience of fluctuations in sexual interest use of a water-based lubricant to ease vaginal discomfort possibility of increased breast sensitivity during sexual activity Explanation: Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. Fluctuations in sexual interest are normal. In addition, breastfeeding women may notice a let-down reflex during orgasm and find that breasts are very sensitive when touched by the partner. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breastfeeding. Use of water-based gel lubricants can help. The Centers for Disease Control and Prevention recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after birth because of the high risk for venous thromboembolism (VTE) during this period.

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply. fundus boggy to the right of the umbilicus dullness on percussion over symphysis pubis elevated oral temperature moderate lochia rubra rounded mass over symphysis pubis

rounded mass over symphysis pubis dullness on percussion over symphysis pubis fundus boggy to the right of the umbilicus Explanation: If the bladder is distended, the nurse would most likely palpate a rounded mass at the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4 degrees F (38 degrees C), infection is suggested.

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage? uterine atony iron deficiency diuresis hemorrhoid

uterine atony Explanation: Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during the postpartum period. Diuresis causes weight loss during the first postpartum week, whereas iron deficiency causes anemia in the puerperium.

Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? uterine atony, placenta previa, operative procedures multiparity, age of mother, operative birth prematurity, infection, length of labor size of placenta, small baby, operative birth

uterine atony, placenta previa, operative procedures Explanation: Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring? The client who is very restless and is moving around in the bed The client who is having an uncomplicated labor The client who is having back labor and desires to lay on her side The client who has had a previous cesarean section

very restless and moving around The client who is restless and frequently changing positions is more likely to have continuous internal electronic fetal monitoring. This method provides data on the fetal heart rate. Depending upon the obstetric history, the client having back labor and the client with an uncomplicated labor may have intermittent fetal heart rate auscultation or external electronic fetal monitoring. The client who had a previous cesarean section would also have monitoring of uterine contraction intensity.

Which suggestion by the nurse about pushing would be most appropriate to a woman in the second stage of labor? "Choose whatever method you feel most comfortable with for pushing." "Let me help you decide when it is time to start pushing." "Bear down like you're having a bowel movement with every contraction." "Lying flat with your head elevated on two pillows makes pushing easier."

"Choose whatever method you feel most comfortable with for pushing." The role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her maternal instinct of when and how to push. In the absence of any complications, nurses should not be controlling this stage of labor, but empowering women to achieve a satisfying experience. Common practice in many labor units is still to coach women to use closed glottis pushing with every contraction, starting at 10 cm of dilation, a practice that is not supported by research. Research suggests that directed pushing during the second stage may be accompanied by a significant decline in fetal pH and may cause maternal muscle and nerve damage if done too early. Effective pushing can be achieved by assisting the woman to assume a more upright or squatting position. Supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.

A pregnant client is admitted to the labor and birth unit in the first stage of labor. A nurse reviews a pregnant client's birth plan. Which response from the client would indicate to the nurse that further teaching is indicate

"I will remain in my bed for my labor and birth like last time."

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to.

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." Explanation: A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A nurse is explaining the various methods of pain control used during labor and birth. When explaining why general anesthesia is rarely used, which information would the nurse include? Select all that apply. In an emergency situation, it takes too long to administer. General anesthesia readily crosses the placenta. Malignant hypothermia is a common side effect in pregnant women. Physiologic changes make it more difficult to intubate a pregnant woman. A pregnant woman has a risk for vomiting and aspiration.

A pregnant woman has a risk for vomiting and aspiration. General anesthesia readily crosses the placent. General anesthesia is not commonly used in labor and birth because all anesthetic agents cross the placenta and affect the fetus. Common complications include fetal depression, uterine relaxation, and potential maternal vomiting and aspiration. Malignant hypothermia is rare and is no more likely to occur in a pregnant client than in a nonpregnant client. General anesthesia can be started quickly and causes rapid loss of consciousness.

Which assessment findings indicate a distressed fetus? Select all that apply. Moderate fetal heart rate variability Absent accelerations Late deceleration patterns Fetal heart rate baseline of 140 Persistent bradycardia

Absent accelerations Late deceleration patterns Persistent bradycardia The nurse evaluates the fetal monitor for normal patterns and/or signs of fetal distress. Absent accelerations, late deceleration patterns and persistent bradycardia indicate client hypoxia. A fetal heart rate baseline of 140 and moderate variability are normal signs.

A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response? Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk. Ask the client to describe the intensity of her pain on a scale of 0 to 10. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication. Assist the client with breathing and imagery techniques in an attempt to calm her down.

Ask the client to describe the intensity of her pain on a scale of 0 to 10. The nurse should first assess the client's pain by asking her to describe the pain on a scale of 0 to 10, as well as evaluate the client's actions. After the assessment, further actions can then be taken, whether that be calling the obstetrician or suggesting nonpharmacologic techniques to help the client calm down. The client should be the one to request the medication, not the spouse. The nurse should not encourage the mother's support person to leave; he or she is necessary for the psychological well-being of the mother.

A primigravida has an office appointment at 39 weeks' gestation. Which assessment data is mostdefinitive of the onset of labor?

Cervical ripening is noted on examination.

The nurse is monitoring a client at 38 weeks' gestation who is bleeding. Which assessment findings indicate the client is hemodynamically unstable? Select all that apply. Fetal heart rate 198 bpm Urine output: 20 ml/hr Blood pressure: 120/78 mm Hg Heart rate: 82 bpm Pulse oximeter: 95%

Fetal heart rate 198 bpm Urine output: 20 ml/h Assessment parameters of hemodynamic stability include heart rate, blood pressure within normal limits, urine output greater than 30 ml/hr, and continuous fetal heart rate monitoring with a rate between 120 and 160 bpm. In this situation, the client's low urine output and high fetal heart rate are signs of being hemodynamically unstable.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which area? muscles of perineal body anal sphincter anterior rectal wall skin

muscles of perineal body The extent of the laceration is defined by depth: a first-degree laceration extends through the skin; a second-degree laceration extends through the muscles of the perineal body; a third-degree laceration continues through the anal sphincter muscle; and a fourth-degree laceration also involves the anterior rectal wall.

Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply. Have a client remain on bed rest with bathroom privileges only. Report an elevated temperature over 38℃ (100.4℉). Position client on the left side throughout the labor process. Answer questions and encourage verbalization of fears. Monitor maternal and fetal vital statistics every hour.

Monitor maternal and fetal vital statistics every hour. Report an elevated temperature over 38℃ (100.4℉). Answer questions and encourage verbalization of fears. Consider what occurs in the latent (or early phase) of the first stage of labor, which are contractions and effacement. The nursing interventions that impact maternal and fetal injury include monitoring vital statistics, reporting temperature elevation over 38℃ (100.4℉), and answering questions and encouraging client verbalization of fears. The client is often excited and talkative. The client does not need to be on bed rest or positioned on the left side unless there is a complication.

The multigravida client is moving into the transition phase and asks for a narcotic, stating she doesn't remember the pain being this bad before. Which response from the nurse will be best? Pain medication can affect the baby's breathing; let's try to focus and breathe." "I will page the provider and ask for your pain medication." "You are so close to birth; don't you want to have natural birth?" "Rather than use a narcotic, let's ask for a different type of pain medication."

Pain medication can affect the baby's breathing; let's try to focus and breathe." Once the woman has entered into the transition phase of labor, she is considered to be imminent for birth. Any opioid medication might pass to the fetus and is not recommended due to the effects of respiratory compromise. The nurse will need to encourage nonpharmacologic methods at this point and should not consult the provider. The nurse should also remain supportive of the mother.

A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize? Assess maternal and fetal vital signs. Ask medical and obstetrical history. Quickly evaluate the perineum. Escort to Labor and Delivery.

Quickly evaluate the perineum. The woman is showing signs of advanced labor, possibly in transition or stage 2. She needs to be managed as an imminent birth and a vaginal assessment performed, as there may not be time to get to Labor and Delivery. Vital signs would be assessed next. Medical/obstetrical history and her room assignment can be taken care of later in the process.

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize? Blood pressure Level of consciousness Respiratory status Maternal heart rate

RR

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? promethazine butorphanol naloxone fentanyl

naloxone

The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which?

The fetus is in the true pelvis and engaged.

Which reason explains why women should be encouraged to perform Kegel exercises after birth? They promote the return of normal bowel function. They promote blood flow, enabling healing and muscle strengthening. They assist with lochia removal. They assist the woman in burning calories for rapid postpartum weight loss.

They promote blood flow, enabling healing and muscle strengthening. Explanation: Exercising the pubococcygeal muscle increases blood flow to the area. The increased blood flow brings oxygen and other nutrients to the perineal area to aid in healing. Additionally, these exercises help strengthen the musculature, thereby decreasing the risk of future complications, such as incontinence and uterine prolapse. Performing Kegel exercises may assist with lochia removal, but that isn't their main purpose. Bowel function is not influenced by Kegel exercises. Kegel exercises do not generate sufficient energy expenditure to burn many calories.

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? Maternal fatigue Maternal hypotension Cord compression Uteroplacental insufficiency

Uteroplacental insufficiency Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.

When assessing a postpartum woman, the nurse suspects the woman is experiencing a problem based on which finding? acute decrease in hematocrit elevated white blood cell count pulse rate of 60 beats/minute increased levels of clotting factors

acute decrease in hematocrit Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. Red blood cell production ceases early in the puerperium, causing mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours. During the next 2 weeks, both levels rise slowly. The white blood count, which increases in labor, remains elevated for first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output. The increase in cardiac output and stroke volume during pregnancy begins to diminish after birth once the placenta has been delivered. This decrease in cardiac output is reflected in bradycardia (40 to 60 bpm) for up to the first 2 weeks postpartum

At which time is it most important to monitor for umbilical cord prolapse? During transitional labor When the fetus is crowning After rupture of membranes At the onset of labor

after rupture of membranes The fetus is at highest risk for umbilical cord prolapse after the rupture of membranes. It is important to assess the fetal heart rate for one full minute. The other options are not as high of a risk.

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering? ataractic antiretroviral benzodiazepine antibiotic

antiretroviral

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Ask her to pant with the next contraction. Help the woman to sit up in a semi-Fowler's position. Turn her or ask her to turn to her side. Administer oxygen at 3 to 4 L by nasal cannula.

ask her to turn on her side The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

Which action is a priority when caring for a woman during the fourth stage of labor? assisting with perineal care assessing the uterine fundus offering fluids as indicated encouraging the woman to void

assessing the uterine fundus During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.

A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as: engrossment. puerperium. attachment. lactation.

attachment. Explanation: Attachment is a formation of a relationship between a parent and her/his newborn through a process of physical and emotional interactions. Puerperium refers to the postpartum period. Lactation refers to the process of milk secretion by the breasts. Engrossment refers to the bond that develops between the father and the newborn.

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as: baseline variability. baseline FHR. short-term variability. fetal bradycardia.

baseline FHR The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.

Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority? Temperature Blood pressure Respiratory rate Pain level

blood pressure Once the epidural catheter is inserted, blood pressure readings are obtained by the nurse every 3 to 5 minutes due to the potential side effect of hypotension. The other options are important to assess but not as directly related to the epidural or as important to monitor as the blood pressure.

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: blue. pink. yellow. olive green.

blue

The nurse is preparing a client for an epidural block. Which intervention is a priority before the epidural anesthesia is started? Increase oral fluids IV fluid bolus Monitor temperature Monitor maternal apical pulse

bolus The client will need to have a bolus of IV fluids prior to the epidural to prevent hypotension. The hypotensive event is transitory, and increasing oral hydration is unnecessary and may lead to nausea later. Monitor the mother's body temperature as per routine. The nurse should monitor the radial pulse not the apical pulse.

There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration? It is generally given PO It can be given frequently without risk to the fetus. It can be administered by the nurse. Fetal monitoring can be safely discontinued.

can be given by the nurse Opioids can be given by the nurse and are most frequently given by the intravenous (IV) route because this route provides fast onset and more consistent drug levels than do the subcutaneous or intramuscular routes. Fetal risks exist, and fetal monitoring cannot necessarily be discontinued once the client receives opioids.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse take in this situation? Perform a vaginal examination to assess cervical dilation (dilatation) and effacement. Stay with the client while reporting the finding to the health care provider. Administer oxygen after turning the client on her left side. Continue to monitor the fetal heart rate because this pattern is benign.

continue to monitor because it is benign Early decelerations are a benign finding and not indicative of fetal distress. They do not require intervention; therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no need to perform a vaginal examination, report the finding to the health care provider nor administer oxygen at this time.

The nurse is caring for a client who is a gravida 2 para 1 and had a previous cesarean section. The client has had no complications with the pregnancy and prefers to have this delivery vaginally. Which monitoring system best assesses for the ability to delivery vaginally? Continuous internal monitoring of uterine contractions Continuous external monitoring of uterine contractions Intermittent monitoring of the uterine resting tone Intermittent fetal heart rate auscultation

continuous internal monitoring Since this client has had a cesarean section, it is helpful to monitor uterine contractions, not resting tone. The nurse would follow the intensity of the contractions to avoid uterine rupture from the previous birth. External monitoring and intermittent fetal heart rate auscultation are noninvasive and not as helpful determining uterine contraction intensity.

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply. contraction pattern estimated date of birth current pregnancy history support system fundal height measurement membrane status

contraction pattern fundal height measurement membrane status As part of the admission physical assessment, the nurse would assess fundal height, membrane status, and contractions. Current pregnancy history, support systems, and estimated date of birth would be obtained when collecting the maternal health history.

A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to:

cranial bones overlapping at the suture lines.

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement

A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as: engrossment. engorgement. involution. mastitis.

engorgement. Explanation: Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn.

A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension? betamethasone ephedrine atropine methylergonovine

ephedrine Explanation: A hypotensive agent such as ephedrine is given to elevate blood pressure if hypotension occurs.

A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds? fetal shoulders fetal back fetal head fetal buttocks

fetal back

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 bpm. The nurse is aware that which factors can result in fetal tachycardia? Select all that apply. narcotic medication to maternal client fetal distress maternal fever uteroplacental insufficiency fetal movement

fetal movement fetal distress uteroplacental insufficiency maternal fever An increase in the FHR (tachycardia) from the baseline can mean that there is fetal movement or some type of fetal distress related to a maternal fever or fetal hypoxia which can be the result of uteroplacental insufficiency. Narcotics would lead to fetal bradycardia.

A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural? Place the woman in the fetal position on the table, and keep her steady so that she won't move during the procedure. Prepare a sterile field with the supplies and medications that will be needed. Administer a fluid bolus through the IV line to reduce the risk of hypotension. Review the woman's medical history and laboratory results, and interview her to confirm all information is accurate and up to date.

fluid bolus Epidurals can cause vasodilatation and result in hypotensive episodes. IV fluid bolus prior to epidural placement can help prevent the hypotensive episode.

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?

frank

A nurse is caring for a client in her third stage of labor. The nurse would predict the placenta is separating from the uterus based on which assessment findings? Select all that apply.

fresh gushing of blood from the vagina umbilical cord descending lower down a globular shaped uterus

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation? Local Short acting Regional General

general

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? hemorrhage hemorrhoids cervical laceration thromboembolism

hemorrhage Explanation: 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

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response? alleviates perineal pain reduces lochia promotes uterine involution improves pelvic floor tone

improves pelvic floor tone Muscle clenching perineal exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk? vessel damage immobility increase in red blood cell production increase in clotting factors

increase in red blood cell production Explanation: Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum (Silver & Major, 2010). This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs. Red blood cell production ceases early in the puerperium, which leads to mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly over the next 2 weeks.

The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation? suggesting that she take frequent warm showers to soothe her breasts instructing her to apply ice packs to both breasts every other hour telling her to limit the amount of fluids that she drinks encouraging the woman to manually express milk

instructing her to apply ice packs to both breasts every other hour If the woman is not breastfeeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breastfeeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen.

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring? Intermittent fetal heart rate auscultation Fetal scalp sampling No monitoring needed Continuous external fetal monitor

intermittent FHR auscultation This client is considered a low-risk pregnancy but some monitoring is still needed. Thus, an acceptable method for monitoring fetal heart rate is intermittent fetal heart rate auscultation. The client is placed on an external fetal monitor for a 20-minute baseline and, if within normal limits, then is checked via a fetoscope or handheld Doppler at intermittent intervals. Continuous external monitoring may be initiated later in the labor process but is not identified from the history. Fetal scalp sampling gives evidence of the fetal status.

A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.

lightening bloody show backache

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next? Continue to monitor the client. Assess the client's vaginal bleeding. Administer oxygen to the client. Continue to massage the client's fundus.

massage The nurse should monitor the client for uterine relaxation. If this is noted, the nurse would continually massage the client's fundus until it no longer felt boggy.

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down? prolactin progesterone oxytocin estrogen

oxytocin Explanation: Oxytocin is released from the posterior pituitary to promote milk let-down. Prolactin levels increase at term with a decrease in estrogen and progesterone; estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production.

A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation?

part of the fetal body entering the maternal pelvis first

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? hyperreflexia urinary retention abdominal distention respiratory depression

respiratory depression Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the woman who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia would be more commonly associated with central nervous system depression due to opioids.

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock? tachypnea and a widening pulse pressure tachycardia and a falling blood pressure bradycardia and auscultation of fluid in the base of the lungs bradypnea and hypertension

tachycardia and a falling blood pressure Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; the nurse should immediately report these signs.

A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure? To decrease the heart rate of the fetus To prevent the woman from falling out of bed To prevent supine hypotension syndrome To aid the woman as she pushes during labor

to prevent supine hypotension syndrome The term "rhythm strip testing" means assessment of the fetal heart rate for whether a good baseline rate and long- and short-term variability are present. For this, help a woman into a semi-Fowler position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to prevent her uterus from compressing the vena cava and causing supine hypotension syndrome during the test. Placing her in this position does not decrease the heart rate of the fetus. It is not done to aid the woman as she pushes in labor, as she is not in labor yet. It is not done to prevent her from falling out of be

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal? two fingerbreadths above the umbilicus two fingerbreadths below the umbilicus at the level of the umbilicus four fingerbreadths below the umbilicus

two fingerbreadths below the umbilicus Explanation: During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.

A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? Select all that apply. FHR baseline changes in baseline types of decelerations rhythm variability

types of decelerations variability Explanation: Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations like electronic fetal monitoring (EFM) can.

A postpartum client reports urinary frequency and burning. What cause would the nurse suspect? subinvolution urinary tract infection stress incontinence uterine atony

urinary tract infection Explanation: Urinary frequency and burning suggest a urinary tract infection. Uterine atony and subinvolution could cause increased blood loss and prolonged lochia. Loss of pelvic muscle tone causes stress incontinence, which results in an inability to hold urine.

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication? inadequate pain block pruritus uterine atony maternal hypotension

uterine atony A complication of general anesthesia is the relaxation of the uterine muscles, leading to uterine atony and possible postpartum hemorrhage. Maternal hypotension, a failed block, and pruritus are side effects of epidural analgesia.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. uterine infection empty bladder prolonged labor early ambulation hydramnios breastfeeding

uterine infection prolonged labor hydramnios Explanation: Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration? early decelerations prolonged decelerations late decelerations variable decelerations

variable Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns. Early decelerations are visually apparent, usually symmetrical and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs, with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency. Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes.