Maternity Exam 2

Which condition poses the greatest risk to a 32-year-old client who is 15 weeks pregnant and has a history of hypertension? Premature separation of the placenta-pg. 368

Abruptio placentae A history of hypertension predisposes the client for developing abruptio placentae. She isn't at risk for developing preterm labor, spontaneous abortion, or anemia

43. A child has just returned from surgery in a hip spica cast. What is the priority nursing intervention? Congenital hip dysplasia-pg. 481

Check the toes for circulation and movement. Check the skin at the edges of the cast for signs of pressure or irritation.

45. What should the nurse expect to be assessing for in a post-term newborn? Post term baby and what to monitor-pg. 444

Monitoring the blood glucose levels, LGA, and shoulder dystocia

14.The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply. S/S of shock-pg. 371

Proteinuria Hypertension

Rh incompatibility can occur if the client is Rh-negative and the:

fetus is Rh-positive. For Rh incompatibility to occur, the mother must be Rh-negative and her fetus Rh-positive. If the fetus is Rh-negative, the blood types are compatible and no problems should occur. The fathers Rh factor is a concern only as it relates to the possible Rh factor of the fetus. If the fetus is Rh-negative, the blood type with the mother is compatible. The fathers blood type does not enter into the problem

3. A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to Post term delivery and the nurse's role-pg. 407

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding. monitor blood sugar, infection, and postpartum hemorrhage.

A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization? A. An Rh negative mother who has an Rh- positive infant B. An Rh -positive mother who has an Rh- negative infant C. An Rh-positive mother who has an Rh- positive infant D. An Rh- negative mother who has an Rh- negative infant

A. An Rh negative mother who has an Rh- positive infant

38. The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause? Reasons for spontaneous miscarriage-pg. 361; 394

Chromosomal abnormality,genetic or congenital abnormalities, and infection are the most common causes. This places the mother at risk for placental abruption.

10. A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer? Do babies born to HIV positive moms get AIDS-pg. 451

"The antibodies may be those transferred across the placenta; the baby may not develop AIDS."

21. The nurse is teaching a couple of a newborn with spina bifida and menigocele about reducing injury to the baby. What teaching should the nurse include? (SATA) spina bifida and meningocele pg. 458

-Avoid putting pressure on the sac during care activities . -Maintaing the newborn in the prone position so that no pressure is placed on the sac. -After surgery continue this positioning until the surgical site is healed.

39. Newborns born to a mother with diabetes are at risk for which of the following and what intervention is priority? Nursing DX and care for a preterm infant-pg. 433

Hypoglycemia, delayed fetal lung maturity, respiratory distress, and shoulder dystocia. assess for hypoglycemia in the newborn as may have hyperbilirubin as well.

28. In which situation would a dilation and curettage (D&C) be indicated? D & C-pg. 74; 362

Incomplete abortion at 10 weeks D&C is carried out to remove the products of conception from the uterus and can be done safely until week 14 of gestation. If all the products of conception have been passed (complete abortion), a D&C is not done. If the pregnancy is still viable (threatened abortion), a D&C is not done.

39. A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority? Nursing DX and care for a preterm infant-pg. 433

Ineffective thermoregulation related to decreased amount of subcutaneous fat.

47.A 26-year-old woman who is nine weeks pregnant presents to the clinic with vaginal bleeding. She reports crampy pelvic pain. Vaginal exam reveals a dilated cervix. Products of conception can be visualized through the cervical. Which of the following best describes this patient's condition? Ectopic pregnancy-pg. 360

Inevitable abortion-prepare the patient for immediate surgery of D&C. Emotionally support the client as the patient is grieving and could be emotionally scard and shocked.

33. A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2° F; (38.4° C) HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs? Infection prevention-pg.410

Infection. The use of prophylactic antibiotics are usually given to a woman after a c-section to help decrease the risk of endometritis.

12. A nurse is assisting a client in active labor whose diabetes has been poorly controlled. Which assessment of the neonate should be prioritized after its birth? Gest. Dm results commonly in what-pg. 330

Macrosomia

31. The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information? Gest. DM and a daily log of BS-pg.

Maintain a daily blood glucose log

37. The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Upon taking her temperature you note her fever of 101.2F. Which of the following should the nurse suspect is the potential diagnosis? Mastitis-pg. 413

Mastitis Explanation: Mastitis usually occurs 2-3 weeks after delivery and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy. The scenario described is not indicative of a plugged milk duct or engorgement. Breast yeast is a distracter for this question.

9. Preterm labor presents as what? Non labor with vaginal discharge and pelvic pressure-pg. 389

Non labor with vaginal discharge and pelvic pressure

44. A nurse is providing postoperative care to an infant who had a ventriculoatrial shunt placed. Approximately 8 hours after surgery, the nurse notes on assessment shrill crying and projective vomiting. Which response should the nurse prioritize at this time? Ventriculoarterial shunt-pg. 459-460

Notify the primary care provider immediately.

2. The nurse is assigned to care for the client after a cesarean section.(most commonly seen with cesarean section) To prevent thrombophlebitis, the nurse encourages the woman to take which priority action? Prevention of DVT Pg. 418

Nursing measures-Ambulation when pain and edema are under control, applying compression stockings, and elevate the affected extremity to prevent VTE.

6. A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury? spina bifida and nursing education-pg. 458

Place the newborn in a prone or lateral position and encourage the parents to cuddle "chest to chest" with the newborn.

29. The nurse is leading a discussion with a group of pregnant women who have pregestational diabetes. The nurse should point out which situation can potentially occur during their pregnancy? And what this looks like. Polyhydramnios-pg. 329

Polyhydramnios-excess levels of amniotic fluid, macrosomia or miscarriage, birth defects, still births, and hypertensive disorders. This is why controlling their blood sugar is so important and should really take caution with their blood sugars.

41. The nurse is educationg pregnant patient diagnosed with diabetes about the causes of Intrauterine growth restriction. What would the nurse inlcude in these teachings? Intrauterine growth restriction reasons-pg. 431

Precipitating factors are diabetes. This could cause hypoglycemia so monitor the blood glucose, and hypothermia as their bodies struggle with thermoregulation. The priority for the nurse and the new mother is to monitor the blood sugar and monitor the body temerature to ensure the baby is warm enough but not too warm.

20. A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation? Premature separation of the placenta-pg. 368

Premature separation of the placenta

You are preparing to administer erythromycin ophthalmic ointment to an infant. The mother is concerned about this medication and asks what is it for? postpartum care of the newborn-

Prophylaxis of ophthalmia neonatorum just in case the baby was exposed to an infection, (to N. gonorrhoeae or C. trachmatis), during birth

37. Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? Mastitis-pg. 413

She should continue to breastfeed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

29. During a presentation about fetal risk. A new mother asks what polyhydramnios would look like in a baby? What is the best response by the nurse? Polyhydramnios (2)-pg. 433

The baby will appear with little muscle or subcutaneous fat, the head and body are disproportionately large and the skin is thin, relatively transluscent, and usually wrinkled.

13. On entering the room of a client who has undergone a dilatation and curettage (D&C;) for a miscarriage at 22 weeks, the nurse finds the client crying. Which of the following comments by the nurse would be most appropriate? Fetal demise and grief support-pg. 394

The death of a fetus at any time during pregnancy is a tragedy for most parents. After a spontaneous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as "I'm truly sorry you lost your baby" is most appropriate. the expectant mother who had already begun to bond with the fetus may not wnat photographs of the incident but later they will be available if she changes her mind.

35. The nurse is teaching new parents about their newborn who was born with respiratory distress syndrome (RDS). The nurse determines the teaching session is successful when the parents correctly choose which explanation as being the cause of their newborn's condition? Respiratory Distress Syndrome (Infant-RDS)-pg. 434

The lungs are immature and deficient in surfactant which is causing the babies lungs to colapse with each breath.

17. The nursing instructor is teaching a new nurse about the parents of a child with a cleft lip and palate. What does the instructor say is the nursing focus for the parents at this time? Cleft lip palate and nursing support-pg. 470

The nurse needs to demonstrate reflective listening and non-judgemental support to the parents.

7. The nurse is assessing a 16 year old pregnant adolescent. The client states she wants to give the baby up for adoption. The parents are mad and yelling. What is the priority role of the nurse with this client? Adolescent pregnancy-pg. 351

The nurse's role is to advocate for the pregnant adolescent in an open and nonjudgemental way.

36. Why does meconium staining occur at birth? Meconium stained fluid-pg. 445

The sphincter of the baby has relaxed and the fetus expels meconium in the amniotic fluid. This puts the baby at an increased risk for respiratory distress.

12. The nurse is explaining about nutrition to the mother at 9 weeks gestation. While speaking to the patient the nurse states that gestational diabetes usually results in what? Gest. Dm results commonly in what-pg. 330

macrosomia baby and the complications of this are shoulder dystocia and the newborn will need to have its foot pricked to monitor the blood sugar.

8. When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? Heavy lochia and uterus boggy, nursing measures-pg. 407

massaging the fundus firmly and note if the bleeding decreases with massage- Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

16. A nurse in the newborn nursery receives a telephone call and is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, the nurse should take which important action? (2) RH and anti-D antibodies-pg. 358

prepare to give RhoGam to the mother within 72 hours after birth if the baby is Rh positive

18. A new mother and her newborn come to the clinic for the checkup after 2 weeks. What statment made by the mother during her assessment gaved her the impression further questions needed to be asked? Post partum depression-pg. 420

"I cry most days and I just don't understand why. I wasn't like this before I gave birth." The nurse needs to understand that 2 weeks of crying and sadness is an indication of postpartum depression and needs intervention.

5. The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie. What intervention should the nurse provide for the client? Transverse lie and the nurse's role-pg. 387

-Some hospitals will try external cephalic version, this is uncomfortable to the patient. If this happens the nurse assists the client with relaxation techniques. -If the hospital does not do external cephalic version you as the nurse need to prepare the patient for an emergency c-section.

4. Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth? C-section

Assess uterine tone to determine fundal firmness.

22. A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to Nurse's role with palpating fundus-pg. 404-407

-palpate her fundus for consistency, shape, and location. The uterus should be firm, midline, and decrease 1cm (below the umbilicus) per day after birth. -Ensure the patient empties her bladder to prevent stasis urine causing infection. -A full bladder can impede uterine contraction, predisposing her to hemorrhage. - Palpating the fundus will cause it to contract and reduce bleeding.

15. Rh incompatibility between a sensitized Rh+ woman and an Rh- fetus can cause what in a newborn? Hemolytic disease-pg. 447

hemolytic disease

40. The nurse knows that a smaller fetus is able to move around more and is at risk of what? Prolapse of umbilical cord and nursing measures-pg. 396-397

-prolapse of umbilical cord and the nurse needs to be notifying the charge nurse or physician and Putting a sterile glove on a hand and entering vagina in order to hold the presenting part off of the umbilical cord during delivery. The replacement of the cord in the uterus should NEVER be attempted -emptying the bladder with a catheter can also assist temporarily to remove the pressure

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

"I will tell the nurse at the hospital that I had RhoGAM during pregnancy."

16. Two days after giving birth, a client is to receive RhoGAM. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: RH and anti-D antibodies-pg. 358

"RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Correct/Explanation: RhoGAM is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. RhoGAM is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

26. The nurse is helping an indigent HIV-positive pregnant patient set up a postdelivery care plan for her baby. What is an appropriate question/statement during that discussion?- HIV mom cannot breastfeed-pg. 451

- Help her find resources-"HIV can be passed to the baby from breast-feeding so it's important that you give the baby formula. Formula's pretty expensive so I'll give you some information for places you can contact if you ever need some help getting it."

29. The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching? Select all that apply. Polyhydramnios (2)-pg. 433

- Increased risk of spontaneous abortion - Polyhydramnios - Hypertension

A client taking magnesium sulfate has a respiratory rate of 10 breaths/min. In addition to discontinuing the medication, which action should the nurse take? Potential toxicity of magnesium -just good info

Administer calcium gluconate Calcium gluconate reverses the effects of magnesium sulfate.

30. When the uterus has subinversion and will not return to its normal size. What is the first intervention by the nurse. Bladder distention-pg.

Assist the patient to urinate.

35. A nurse is monitoring a preterm newborn infant for signs of respiratory distress syndrome (RDS). The nurse monitors the infant for: If these signs are found the nurse would with what? Respiratory Distress Syndrome (Infant-RDS)-pg. 434

Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring. The baby appears to be in distress. I will notify the charge nurse and provide intervention.

1. Between her regularly scheduled visits, a woman in her first trimester of pregnancy who is taking iron supplements for anemia calls the nurse at her obstetrician's office complaining of constipation. She reports that she has never had this problem before and asks for some advice about how to get relief. What is the best advice the nurse can give her? Iron and constipation nursing measures pg. 338

Encourage her to continue taking iron supplements but increase fluids and high-fiber foods; exercise more.

46. An 18-year-old woman comes to the emergency department with sudden onset of right lower abdominal pain. She describes the pain as crampy and intermittent. Her last menstrual period was 7-weeks ago. She has noticed vaginal spotting during the past few days. Ectopic Pregnancy-pg. 360

Ectopic pregnancy

19. A postpartum mother comes into the clinic at her 6 weeks checkup. The patient displays excessive euphoria and becomes agitated with the infant during the assessment. What does the nurse suspect is the best explanation? Post partum psychosis-pg. 422

The nurse recognizes the signs that mimic bipolar disorder and understand this is postpartum psychosis. Intervention needs to happen immediately as both mother and baby are at risk for injury. A postpartum mother with psychosis is usually unable to provide cae for her infant.

34. The nurse is teaching a pregnant client about iron supplements and what helps with iron absorption. What does the nurse recommend the client use to drink with iron supplement? What helps with iron absorption?-pg. 337

The nurse would recommend using orange juice that has Vit C. to assist with the absorption of iron supplement.

27. A patient presents to the clinic with reports of positive home pregnancy test. What does the nurse anticipate to find on the ultrasound? Transvaginal ultrasound indicates a gestation sac-pg. 360

Transvaginal ultrasound indicates a gestation sac if the patient is pregnant. If not the nurse need to think about ruling out ectopic pregnancy and report the findings to the provider.

23. The nurse is assessing a primigravida woman who reports vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. The nurse suspects the woman has contracted which disorder? Trichomoniasis-pg. 345

Trichomoniasis

25. What is a rare obstetrical emergency that occurs when the uterus tears open, exposing the fetus and other uterine contents to the peritoneal cavity Uterine rupture-pg. 397

Uterine rupture

11. A nurse is caring for an infant who has had a spica cast placed for dysplacia of the hip. The mother reports the infant is vomiting after a feeding, no fever is present during the assessment. What is the priority nursing measure? Hip dysplasia surgery in a spica cast and side effects-pg. 482

Vomiting after a feeding could sign that the cast is too tight over the stomach. In either case the cast may have to be removed and reapplied.

4. The pregnant mother asks the nurse what are the pros and cons of c-section vs vaginal birth. What is the best response by the nurse? C-section Vs. vaginal birth-pg. 224

When the baby passes through the birth canal in vaginal birth this action squeezes the fluid from the lungs of the newborn. In a c-section this does not happen and puts the baby at a risk for respiratory distress.

A client reporting she recently had a positive pregnancy test has reported to the emergency department stating one-sided lower abdominal pain. The health care provider has prescribed a series of tests. Which test will provide the most definitive confirmation if it is or isn't an ectopic pregnancy?

abdominal ultraound indicates a gestational sac.

a newborn is showing signs of jaundice and what does the nurse suspect would be the labs will show? Hemolytic disease-pg. 447

acute bilirubin encephalopathy which is a hemolytic disease

A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client? Potential toxicity of magnesium and what will nurse assess-pg. 390 table 18-2

diminished reflexes

A client who was pregnant had a spontaneous abortion at approximately 4 weeks gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the client presents at the clinic office complaining of crampy abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100 F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/min (bpm), and respirations, 20 breaths/min. Based on these assessment data, what does the nurse anticipate as a clinical diagnosis? D & C-pg. 74; 362-endometritis-pg. 410

endometritis The client is exhibiting signs of uterine infection, with elevated temperature, vaginal discharge with odor, abdominal pain, and blood pressure and pulse manifesting as shock-trended vitals. Because the pregnancy test is negative, an undiagnosed ectopic pregnancy and gestational trophoblastic disease are ruled out. There is no supportive evidence to indicate a clinical diagnosis of endometriosis at this time; however, it is more likely that this is an infectious process that must be aggressively treated.

36. A nurse is caring for a newborn whose chest X-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. For which dangerous condition should the nurse prepare when providing care to this newborn? meconium aspiration syndrome-pg. 445

meconium aspiration syndrome-pg. 445

32. After assessing a client's progress of labor, the nurse suspects the fetus is in what position based on the client reporting severe back pain? Occiput posterior position-pg. 386

occiput posterior position

24. A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out? Prevention of maternal D body formation-pg. 359

prevent maternal D antibody formation.

T42. he following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity? Potential toxicity of magnesium and what will nurse assess-pg. 390 table 18-2

reflexes

36. Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid? Meconium stained fluid-pg. 445

respiratory rate of 60 to 70 bpm

20. A pregnant woman is diagnosed with abruptio placentae. When reviewing the woman's medical record, the nurse would expect which finding? Premature separation of the placenta-pg. 368

sudden dark red vaginal bleeding, a rigid boardlike abdomen, hypertonic labor, and fetal distress. The pain has a sudden onset and is constant. The uterus is firm to rigid to the touch with abruptio placentae; it is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. Bright red vaginal bleeding is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation

uterine atony has increased risk for hemorrhage and may need a D&C to clear out all the placental fragments. Why would this need to be done? Post term delivery and the nurse's role-pg. 404

to reduce the risk of hemorrhage and infection.

25. A client is admitted to the L & D suite at 36 weeks' gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms? Uterine rupture-pg. 397

uterine rupture -rule out uterine rupture-teacher said notes-