Maternity

When does Rh incompatibility occur?

Only when the mother is Rh negative and the fetus is Rh positive. Rh incompatibility occurs only when the mother is Rh negative and the fetus is Rh positive; this happens when the father of the fetus is Rh positive.

The nurse is assisting with data collection on a woman in her first trimester of pregnancy. Which findings should be reported to the health care provider immediately? (Select all that apply.) a. Cramping with bright red spotting b. Increased urination c. Lack of breast tenderness d. Increased amount of vaginal discharge e. Right-sided flank pain

a. Cramping with bright red spotting c. Lack of breast tenderness e. Right-sided flank pain Cramping with bright red spotting and lack of breast tenderness could indicate that miscarriage is occurring. Option E could be an indication of an ectopic pregnancy, which could be fatal if not treated before rupture. Options B and D are common occurrences during the first trimester of pregnancy.

Which factor is most important for the nurse to assess when evaluating the effectiveness of methylergonovine maleate (Mertergine)?

Amount of vaginal bleeding Methylergonovine maleate is used to control postpartum uterine bleeding. The most objective measure of this is the amount of vaginal bleeding. The height of the fundus is not the main factor because the height must be evaluated in conjunction with the degree of contraction/bogginess of the fundus, position of the fundus relative to midline, and volume of urine in the bladder. Methylergonovine maleate induces uterine contractions, but the drug is used to control bleeding, not simply to induce contractions. Therefore, this is not a direct measure of the drug's effectiveness. Methylergonovine maleate is not used to affect the letdown reflex.

What are the most appropriate patient problems for a breast-feeding mother? (Select all that apply.)

Anxiety related to lactation expectations Imbalanced nutrition: less than body requirements related to the demands during lactation Potential for infection related to dry, cracked nipples

The nurse teaches care of the umbilical cord to a new mother. What instruction will the nurse provide?

Apply alcohol on the cord stump daily to keep it dry until it falls off. The cord stump needs to be kept dry, and applying alcohol daily will help keep the stump dry until it falls off. The cord stump needs to be kept dry; applying Vaseline will not accomplish this. The cord stump needs to be kept dry, so soaking is not appropriate. The cord stump should be allowed to fall off naturally by being kept dry.

The nurse observes a new mother turning away from her infant and sighing deeply. Which intervention would be most appropriate for the nurse?

Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming." Often new mothers feel overwhelmed; allowing them time to discuss their feelings and fears will help promote bonding with their children. Further assessment needs to be done to determine if there is a spiritual problem and a need for the chaplain to be contacted. The signs of rejection are not the same as the signs of pain; thus, further assessment would need to be done. This is not a normal experience after childbirth, so ignoring it would be inappropriate.

The father's behavior when introduced to his new baby is typically an intense fascination. What is this behavior considered?

Engrossment A new father's behavior of typical intense fascination is called engrossment. Bonding is also known as parent-child attachment, but is not limited to the father. Enforcement or taking-in does not refer to the father's fascination with his new baby.

A patient has been ordered oxytocin (Pitocin) to induce labor. Which medication currently taken by the patient would cause the nurse to hold oxytocin (Pitocin)?

Ephedrine sulfate (Pretz D) Ephedrine sulfate is a vasopressor. Concurrent use of oxytocin and vasopressors can result in severe hypertension. Acetaminophen, MOM, and penicillin are not contraindicated for a patient taking oxytocin.

During a postpartum check, the nurse assesses the new mother's uterus and notes it to be boggy. What is the nurse's first intervention?

Gently massage the fundus to increase contractility. Gently massaging the fundus will increase the contractility of the uterus, decreasing the risk for uterine hemorrhage. Contacting the health care provider for medication would occur if the nurse could not get the fundus to firm backup. The nurse should have instructed the patient to void before assessing the fundus. This is how the nurse would assess the perineum and rectum, not the fundus.

A 25-year-old client has a positive pregnancy test. One year earlier she had a spontaneous abortion at 3 months' gestation. What is the description that the practical nurse (PN) should use to document gravida and parity in this client's medical record?

Gravida 2, para 0 This is the client's second pregnancy or second "gravid" event, the spontaneous abortion occurred at 3 months' gestation (12 weeks), so she is a para 0. Parity when delivery occurs at 20 weeks' gestation or beyond.

A new mother reports feeling weak, light-headed, and being sick to her stomach. The LPN/LVN also notes that the patient's perineal pad is soaked since she last checked it 15 minutes ago. The patient's skin is cool and clammy. The pulse is 110 beats/min and the blood pressure is 80/60. What complication do these symptoms indicate?

Hypovolemic shock The identified signs and symptoms show the patient to be going into hypovolemic shock. A patient with a puerperal infection would have a temperature of 100.4° F or higher on 2 successive days during the first 10 days after delivery. This patient's skin is cool. Pregnancy-induced hypertension occurs during pregnancy. This patient has already given birth. Preeclampsia is an abnormal condition of pregnancy characterized by the onset of acute hypertension after the 24th week of gestation. This patient has already given birth.

A patient who is 9 weeks pregnant comes to the hospital complaining of vaginal bleeding. An ultrasound reveals no heartbeat or uterine growth. The patient is to be scheduled for a D & C. What type of abortion is this?

Incomplete spontaneous abortion Incomplete spontaneous abortion is the termination of pregnancy before 20 weeks and some, but not all, of the products of conception are expelled. Threatened spontaneous abortion is unexplained bleeding and cramping. The fetus may or may not be alive. Membranes remain intact and the cervical os remains closed. Inevitable spontaneous abortion is when bleeding increases and the cervical os begins to dilate. Membranes may rupture. Complete spontaneous abortion is when all the product of conception is expelled from the uterus.

Which physical signs and symptoms might the postpartum patient experience following delivery? (Select all that apply.)

Increased urination beginning 4 to 6 hours after delivery A normal bowel movement within 2 to 3 days Increased diaphoresis, most commonly at night

Which vitamin does the nurse anticipate will be given to a newborn to prevent hemorrhage?

K Vitamin K is a fat-soluble vitamin necessary for the production of the blood clotting factors prothrombin (factor II), proconvertin (factor VII), plasma thromboplastin component (factor IX), and Stuart factor (factor X) in the liver. Vitamin K is absorbed from the diet and is normally produced by the bacterial flora in the gastrointestinal tract, from which it is absorbed and transported to the liver for clotting factor production. Newborns have not yet colonized the colon with bacteria and are often deficient in vitamin K. They may also be deficient in these clotting factors and are therefore more susceptible to hemorrhage disease in the first 5 to 8 days after birth. Vitamins B12 and E and folic acid do not prevent hemorrhage in newborns.

While assessing a laboring patient, which fetal heart tone (FHT) would the nurse consider cause for further or constant monitoring?

Late deceleration Late decelerations are an indication that there may be uteroplacental insufficiency. The fetus may not be getting enough oxygen. Constant monitoring will be needed to make sure the fetal heart tones do not decrease to the point of demise. Early decelerations are an indication of head compression. Accelerations are not a characteristic of FHTs. This is a normal count for FHTs.

After delivery, a newborn is classified according to weight at any given gestational age. What would a newborn weighing 2500 g or less be classified as?

Low birth weight (LBW) At birth, an infant who weighs 2500 g or less is classified as LBW. LGA is weight above the 90th percentile. SGA is weight below the 10th percentile. AGA is weight between the 10th and 90th percentiles.

Which location does the nurse place ophthalmic ointment in an infant?

Lower conjunctival sac Ophthalmic ointment should be instilled into the lower conjunctival sac. Instill a ¼ inch ribbon along the lower conjunctival surface of both eyes. Ophthalmic ointment should not be placed directly into the center of the eye, at the bottom of the upper eyelid, or in the inner canthus of the eye.

Which assessment is appropriate for the nurse to implement with an infant whose mother has been taking magnesium sulfate before delivery?

Respiratory depression As in the mother, hypermagnesemia may cause respiratory depression in the infant. The infant may experience hypotension, not hypertension. The infant may not urinate for a period of time after delivery; this is not a critical indication of problems from magnesium in the infant. The infant may experience hyporeflexia, not hyperreflexia.

A patient delivered her infant 36 hours ago. She is sitting in bed when she feels a gush of warm fluid between her legs. She calls the nurse, who finds her bleeding. This is an example of late postpartum hemorrhage. What is the most common cause of late postpartum hemorrhage?

Retained fragments of the placenta The most common cause of late postpartum hemorrhage is retained fragments of the placenta. Uterine atony, a retained placenta, and laceration of the perineum are common causes of early postpartum hemorrhage.

The nurse is assessing a primipardum woman whose labor is being induced with oxytocin (Pitocin). Assessment findings include blood pressure 138/86, pulse 80, respirations 22, fetal heart rate (FHR) of 156, and strong 96-second contractions. Which action does the nurse implement?

Slow the infusion to a keep open rate. The infusion should be slowed to a keep open rate and the physician or midwife notified. Contractions of 96 seconds every 2 minutes do not allow adequate blood flow to the fetus because blood flow requires uterine relaxation. Oxygen is administered and the mother turned onto her left side if fetal distress occurs. Fetal distress is indicated by tachycardia, followed by bradycardia. An FHR of 156 is within the normal range of 120 to 160 beats/min. Use of an infusion pump and a tocometer is standard practice whenever oxytocin is used to induce or support labor

A patient with a family history of pregnancy-induced hypertension (PIH) asks the nurse if there is a cure. What information will the nurse give to this patient?

Termination of the pregnancy The only known cure for PIH is the termination of the pregnancy.

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. What instruction should the practical nurse (PN) reinforce to this client?

a. Breastfeed the infant, ensuring that both breasts are completely emptied. Mastitis (caused by plugged milk ducts) is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue.

The nurse is assisting with data collection on a client who is in her last trimester of pregnancy. Which findings should the nurse report urgently to the health care provider? (Select all that apply.) a. Increased heartburn that is not relieved with doses of antacids b. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit c. Shoes and rings which are too tight because of peripheral edema in extremities d. Decrease in ability for the client to sleep for more than 2 hours at a time e. Headaches that have been lingering for a week behind the client's eyes

a. Increased heartburn that is not relieved with doses of antacids e. Headaches that have been lingering for a week behind the client's eyes Intractable indigestion and lingering headaches are not unusual during pregnancy, but can be symptoms of preeclampsia and should be reported to the health care provider. The fetal heart rate normally ranges between 120 and 160. Peripheral edema and difficulty sleeping are common during pregnancy and do not warrant immediate notification of the health care provider.

A new mother asks the practical nurse (PN), "How do I know that my daughter is getting enough breast milk?" Which explanation best supports that the mother has adequate milk supply?

b. "Your milk is sufficient if the baby is voiding pale, straw-colored urine 6 to 10 times a day." The urine will be dilute (straw-colored) and frequent (greater than six to ten times/day) if the infant is adequately hydrated.

The findings of a maternal triple screen test indicate that an 18-week primigravida has an elevated serum alpha-fetoprotein (AFP) level. Which information is best for the practical nurse to provide?

b. Elevation of any part of this test may indicate the need for further studies. A maternal triple screen test measures the serum levels of AFP, human chorionic gonadotrophin (hCG), and maternal estriol, and it is performed between 15 and 21 weeks' gestation to identify serum levels associated with Down syndrome, other chromosomal defects, or neural tube defects, such as spina bifida.

Which actions by the nursing mother will support milk production and promote infant comfort? (Select all that apply.)

Drink 8 to 10 glasses of fluids daily. Avoid spicy foods, chocolate, and onions. Continue her prenatal vitamins and minerals until they are gone.

When assessing cultural preferences of a laboring patient, the nurse remembers to ask about traditional birth practices. Which birth practice is most common in non-American cultures?

Father is not present In southeast Asia, Laos, India, and Iran, the most common practice is that the father is not present during the birth of a child. Stoicism about the pain of childbirth is unique to the culture of Mexico. Burying the placenta for good luck is unique to cultures of American Indians. Having both the father and female relatives present at birth is unique to the culture of Mexico.

What are the signs and symptoms of maternal hyperglycemia? (Select all that apply.)

Frequent urination Disorientation Flushed hot skin Fatigue

The nurse is instructing a new mother about treatment for mastitis. Which statement by the patient indicates the need for further teaching?

"I will need to stop breast-feeding until the infection is gone." The patient will need to continue breast-feeding or use a breast pump to empty the breast and prevent milk stasis. The other statements indicate an understanding of mastitis by the patient.

The nurse is teaching a patient about the use of clomiphene citrate (Clomid). Which statement by the patient indicates a need for further teaching?

"It is not necessary to take my temperature while taking this drug." Basal temperatures should be taken and followed for 1 month after therapy. The other statements indicate a proper understanding of the use of clomiphene citrate. The patient should have intercourse during the time of ovulation, which is usually 6 to 10 days after the last dose of medication.

A patient has been admitted with preeclampsia. Following an assessment, the nurse notes the patient has edema of the face, hand, and abdomen. How would the nurse document this finding?

3+ Edema of the face, hands, sacrum, and abdomen is documented as 3+. Minimal edema on pedal and pretibial areas is documented as 1+. Obvious edema of the lower extremities is documented as 2+. Massive, generalized edema is documented as 4+.

Before discharge, what information should the practical nurse (PN) give to parents regarding the newborn's umbilical cord care at home?

Allow the cord to air dry as much as possible. Recent studies indicate that air drying or plain water application may be equal to or more effective than alcohol in the cord-healing process

A pregnant woman receiving magnesium sulfate develops magnesium toxicity. Which antidote does the nurse anticipate will be ordered by the healthcare provider?

Calcium gluconate A 10% solution of calcium gluconate should be kept at the patient's bedside ready for use. The dosage is 5 to 10 mEq (10 to 20 mL) intravenously over 3 minutes. Vitamin K, protamine sulfate, and terbutaline have no effect on elevated magnesium levels.

Which characteristics are indications of true labor? (Select all that apply.)

Contractions get stronger with ambulation. Contractions follow a regular pattern. The cervix softens, effaces, and dilates.

A pregnant patient comes to the hospital saying she thinks her water has broken. The nurse checks the fluid with Nitrazine test paper to determine if the fluid is amniotic fluid or vaginal secretions. What color will the nurse expect the paper to turn if the fluid is amniotic?

Deep blue The Nitrazine paper will turn blue-green (pH 6.5), blue-gray (pH 7.0), or deep blue (7.5) if the fluid is amniotic because it is slightly alkaline. Olive-green, olive-yellow, or yellow indicates that the fluid is acidic. Amniotic fluid is slightly alkaline.

A dinoprostone (Cervidil) 10-mg vaginal insert is ordered for a primipardum woman at term to induce cervical ripening. Which factor must the nurse consider when planning care for this patient?

Dinoprostone must be removed at the onset of labor or 12 hours after insertion. When dinoprostone is used to induce cervical softening and dilation before labor, the slab is placed in the posterior fornix of the vagina and is removed at the onset of labor or after 12 hours. Dinoprostone does not need to be prewarmed. The patient needs to remain supine for 2 hours after insertion, but can be ambulatory thereafter. The patient needs to be monitored for orthostatic hypotension, not hypertension and dysrhythmias.

When is Rho(D) immune globulin (RhoGAM) is typically administered?

During the 28th week of gestation and within 72 hours of delivery Rho(D) immune globulin should be given after confirmation of the mother's Rh status—she must be Rh negative—and during the 28th week of gestation and within 72 hours of delivery. The drug being administered immediately following delivery is only part of the required therapy. Rho(D) immune globulin should be given before 32 weeks' gestation and may be administered after either a vaginal delivery or a cesarean delivery. Rho(D) immune globulin should not be given during the first trimester of pregnancy.

What is the term for shortening and thinning of the cervix during the first stage of labor?

Effacement Effacement is the process of shortening and thinning of the cervix. Effacement is complete when only a thin edge can be palpated. Dilation is the process of the cervix and cervical canal enlarging and widening of the cervical opening. Contractions are tightening of the pregnant uterus that can be regular or irregular and cause the progression of dilation and effacement. Scarring is the result of a prior infection or surgery of the cervix and may slow cervical dilation.

Which ophthalmic ointment does the nurse anticipate will be given to a newborn immediately after birth?

Erythromycin (Ilotycin) Erythromycin is a macrolide antibiotic used prophylactically to prevent ophthalmia neonatorum, which is caused by Neisseria gonorrhoeae. It is also effective against Chlamydia trachomatis. Gentamicin is not used in newborns immediately after birth. Triple dye is not instilled in the newborn's eyes; it is used to dry out the umbilical cord. Bacitracin is not used in the newborn's eyes immediately after birth.

A patient is receiving dinoprostone (Cervidil) for the treatment of a benign hydatidiform mole. Which adverse effect might the nurse assess in this patient?

Fever Fever, including chills and shivering, may occur in patients taking dinoprostone. Diarrhea, not constipation, is an adverse effect of dinoprostone. Edema is not an adverse effect of dinoprostone. Orthostatic hypotension, not hypertension, is an adverse effect of dinoprostone.

A nurse is writing a care plan for a diagnosis of imbalanced nutrition: less than body requirements. What is the most common nutrition-related discomfort of pregnancy?

Hyperemesis gravidarum Hyperemesis gravidarum is one of the most common nutrition-related discomforts of pregnancy, because of the lack of fluid and food intake leading to metabolic problems. Lack of fluid and food intake during pregnancy can lead to metabolic problems but is not related to spontaneous abortion. An ectopic pregnancy is when the fertilized ovum implants outside the uterus. This is not related to a lack of fluid or food intake during pregnancy. A multifetal pregnancy involves more than one fetus in the uterus. It is not related to a lack of fluid or food intake during pregnancy.

The health care provider is performing the Leopold maneuver on a laboring patient to check for fetal position. What is the most common position for delivery?

LOA LOA stands for left occipitoanterior, the most common position for delivery. ROP stands for right occipitoposterior. It is not the most common position for delivery. ROA stands for right occipitoanterior. It is the second most common position for delivery. LOP stands for left occipitoposterior. It is not the most common position for delivery.

The nurse is caring for a patient in labor. While assessing the patient's vital signs, the nurse notes a drop in the patient's blood pressure. To prevent supine hypotension, the nurse should encourage the patient to be in what position?

Left lateral side lying A left lateral side-lying position helps reduce pressure on the maternal vessels and prevents their compression. The Trendelenburg's position or supine position will not relieve the pressure the uterus puts on the aorta and vena cava. The right lateral side-lying position will not relieve the pressure the uterus puts on the aorta and vena cava.

When a pregnant patient is being monitored for preeclampsia, fetal condition is also monitored. If the health care provider requests a kick count, how many counts per hour would be considered to be a concern?

Less than 3 counts per hour Fetal activity decreases if hypoxia develops; therefore, fetal activity less than 3 counts per hour is considered serious and needs to be reported.

A patient is receiving magnesium sulfate for the treatment of preeclampsia. What does the nurse monitor for if the patient's magnesium level is 10.2 mg/dL?

Loss of deep tendon reflexes Early signs of maternal toxicity are reports of "feeling hot all over" and "being thirsty all the time," flushed skin, and diaphoresis. Patients may then become hypotensive and have depressed patellar, radial, biceps reflexes, and flaccid muscles. Later signs of hypermagnesemia are central nervous system (CNS) depression shown first by anxiety, then confusion, lethargy, and drowsiness. If serum levels continue to increase, cardiac depression and respiratory paralysis may result. Blood pressure in patients with high magnesium sulfate levels becomes hypotensive, not hypertensive. Later signs of hypermagnesemia are CNS depression shown first by anxiety, then confusion, lethargy, and drowsiness. Insomnia is not noted with this magnesium level. Increased urine output is not a symptom of hypermagnesemia at this level. Individuals usually experience decreased urine output with increasing magnesium levels.

The laboring patient has just had membranes ruptured by the health care provider. The amniotic fluid is greenish-brown in color. What does this abnormal finding indicate?

Passage of meconium stool by the fetus The greenish-brown color of amniotic fluid is an indication of the passage of meconium stool by the fetus that can lead to hypoxic episodes in the fetus. Premature separation of the placenta would have port wine-colored amniotic fluid. Intrauterine infection is characterized by thick, cloudy, foul-smelling amniotic fluid. Yellow-stained amniotic fluid is an indication of fetal hemolytic disease or an intrauterine infection.

The vital signs of a newborn baby girl are: T—97.9, P—140, R—34 with brief periods of apnea, and B/P—80/40 with an increase in systolic pressure when crying. What is the nurse's next intervention?

Realize these vital signs are normal for a newborn and document the data on the flow sheet. The baby's vital signs fall within the normal ranges for a newborn; therefore, the nurse would document the data. The heart rate would need to be greater than 140 beats/min to be considered tachycardia. The respiratory rate would need to be greater than 60 breaths/min to be considered abnormal. A newborn with a temperature less than 97.4 would be assessed for hypoglycemia.

When the delivery of the placenta is complete, which stage of labor is complete?

Third stage The delivery of the placenta completes the third stage of delivery, lasting approximately 5 to 20 minutes. The first stage of labor ends with the complete dilation of the cervix. The second stage of labor ends with the birth of the baby. The fourth stage of labor ends when the mother's vital signs are observed to be within normal ranges 2 to 4 hours after the birth.

During labor, a client is experiencing a fetal heart rate of 68, which lasts longer than 45 seconds. Which is the nurse's first action?

a. Turn the client to her left side. The client should be turned to her left side immediately, as turning her may take the weight of the uterus and reduce the pressure the heavy uterus is placing on the client's blood vessels. Administering oral fluids may be contraindicated, because a Caesarian section may be required if the fetal bradycardia persists. The client's symptoms do not correlate with a blood sugar disorder. Assessing the client's vital signs and oxygen saturation is necessary, but it is not a priority action.

During a prenatal visit, the practical nurse (PN) discusses with a client the effects that smoking has on the fetus. The nurse realizes the teaching is effective if the client identifies which possible effect on the fetus?

b. Lower initial weight documented at birth. Smoking is associated with low-birth-weight infants.

When a client who delivered an 8-pound, 12-ounce infant 6 hours earlier is ambulating to the bathroom for the second time since delivery, the practical nurse (PN) observes blood running down her leg. What action should the PN take?

c. Assist the client back to bed and check her fundus. The client who delivers a large-for-gestational age (LGA) infant is at risk for postpartum hemorrhage because of uterine atony. The nurse should assist the client to bed and assess the consistency of the fundus. A fundus that is boggy or displaced from the midline can predispose the client to bleeding.