Maternity Exam 3 Cumulative Review Questions

Occult Prolapse, Cord Prolapsed in front of Fetal Head, Complete Prolapse

- *occult/hidden* → cord between fetal presenting part & pelvis; can't be seen or felt - *in front of head* → can't be seen but felt as pulsating mass - *complete* → cord seen protruding from vagina

Precipitous Labor

- *rapid birth* occurring w/in *3 hrs of labor onset* - abrupt onset of strong contractions - associated w/ abruptio placentae, fetal meconium, maternal cocaine use, postpartum hemorrhage, low APGAR scores - *priority nursing intervention* → fetal O2

Pre-Term Labor

- *20-37 wks* gestation - *complaints, s/s* → feels like starting of period, doesn't feel right, very broad s/s, contractions, low back pain, increased vaginal discharge,

McRoberts Maneuver & Suprapubic Pressure

- *McRoberts* → woman flexes thighs tightly against ab, which straightens the pelvic curve - *suprapubic* → pushed fetal anterior shoulder down to displace it from mother's symphysis pubis (more risk for clavicle break) - NEVER FUNDAL PRESSURE

Uterine Rupture: Treatment

- *emergency C-section* (get baby out ASAP) - stabilize mom/infant - hysterectomy for large uterine rupture

Soft-Tissue Abnormalities

- *full bladder* → reduces available space in pelvis & intensifies discomfort - woman should void q1-2hrs, possible catheterization

Pelvis Types

- *gynecoid* → most common, round/cylindrical/ shape - *anthropoid* → long, narrow oval - *android* → heart/triangle-shaped pelvic inlet - *platypelloid*→ flattened, wide/short/oval - risk for *uterine rupture*

Measures to Relieve Pressure with Umbilical Cord Prolapse

- *hand up vagina* pushing head up/off the cord - *knee-chest* position uses gravity to shift fetus out of pelvis - *trendelenburg* → head down position, mixed w/ hips elevated w/ 2 pillows *BEST OPTION: counter traction on fetal head*

Dysfunctional Labor: Problems with "Powers"

- *ineffective contractions* → hypotonic & hypertonic, IUPC is definitive dx - *ineffective pushing* → due to exhaustion, psychological issues, fear of pain, incorrect technique, anesthesia; let mom rest/tug of war

Pre-Term Labor: Risk Factors

- *infections*, *obesity*, *uterine/cervical/fetal anomalies*, *chronic condition* - *previous preterm*, SAB, preg losses, *incompetent cervix/short cervical length*, *in-vitro fertilization/other assistive technologies* - *smoking*, drug use, poor nutrition, extremes in age, *little/no prenatal care*, *low education/socioeconomic status*, stress, *domestic violence* - *oligo/polyhydramnios*, *uterine distention/irritability/bleeding*, anemia, *preeclampsia*, *PPROM*

PROM: Complications

- *infx* - *chorioamnionitis* (intraamniotic infx/inflammation of amniotic sac) → maternal fever, uterine tenderness - *oligohydramnios* → caused from slow leakage of amniotic fluid → cord compression, reduced lung volume, & deformities

Pre-Term Labor: Nursing Care

- *initial measures* → identify/treat infx, identify other causes for preterm contractions (dehydration), limit activity, hydration - *steroid admin* increase lung maturity - *tocolytics* → Mag sulfate, Ca+ antagonists, prostaglandin synthesis inhibitors, beta-adrenergics

Premature Rupture of Membranes (PROM)

- *rupture of the sac before the onset of true labor* - most women begin spontaneous labor in 12-24 hrs - *risk factors* → infx, chorioamnionitis, mom w/ previous PROM/PPROM, overextension of uterus, intercourse, cervical incompetency - *treatment* → antibiotics, term babies wait a few hours & if still not in normal patterns, *admin pitcocin*, bedrest, *NOTHING goes into pelvis*, hydrate w/ IV fluids, treat infx, keep baby inside as long as possible - *diagnostics* → amniocentesis

Placenta Increta

- 15%, grows through desidua & into uterine muscle - may cause hemorrhage

Placenta Percreta

- 5%, grows through desidua & uterine muscle, AND all the way through attaching to other organs - may cause hemorrhage

Placenta Accreta

- 75%, attached too deeply into uterine lining, causing placenta to not want to detach - may cause immediate/delayed hemorrhage after birth

Prostaglandin Synthesis Inhibitors

- Indocin inhibits stimulation of uterine contractions, reduces amount of amniotic fluid - *common side effects* → constriction of ductus arteriosis, pulmonary HTN, oligohydramnios

Calcium Antagonists

- Nifedipine (Procardia) given for HTN - blocking Ca2+ reduces muscular contractions - *common side effects* → flushing of skin, headaches, transient increase in HR, maternal hypotension

Anaphylactoid Syndrome

- amniotic fluid embolism (AFE) (emergency!!) - amniotic fluid drawn into maternal circulation & carried to woman's lungs → obstructing pulmonary BVs - *s/s* → hypoxemia, resp distress, depressed cardiac fx, circulatory collapse, DIC (disseminated intravascular coagulation) - *risks/complications* → sepsis, preeclampsia, cardiac disease

Fetal Anomalies

- breech & transverse lie associated w/ anomalies - ex. → hydrocephalus, large fetal tumor

Prolonged Labor

- causes increased infection risk for mom/baby, maternal exhaustion, high levels of fear anxiety - release *catecholamines that inhibit uterine contractions*

OP (Occiput Posterior)

- change position of mom, hands on knees, side-lying, lunge, squat/sit/kneel/stand while leaning forward - *s/s* → "back labor" - mom may use *birthing ball* to help

Betamethasone

- corticosteroid, accelerates fetal lung maturity to avoid resp distress syndrome

Shoulder Dystocia

- delayed/difficult & unpredictable *birth of shoulders impacted above maternal symphysis pubis* - *s/s* → turtle's sign, failure of shoulders to externally rotate - *nursing interventions* → McRoberts maneuver, suprapubic pressure - *after birth interventions* → check clavicle for crepitus/deformity/bruising, brachial plexus/nerve injury to neck/shoulder area

Signs Associated with Intrapartum Infection

- fetal tachycardia ( > 160 bpm) - maternal fever (38 C or 100.4 F) - cloudy/yellow amniotic fluid - uterine tenderness

Face Presentation

- head diameter similar to vertex presentation - *face first*

Velamentous Cord Insertion

- insertion into fetal membrane instead of central to placenta - risk for fetal death when membranes rupture

Prolonged Pregnancy

- lasts longer than 42 wks - most are miscalculations of EDD (ultrasonography most accurate for EDD)

Prolonged Pregnancy: Complications

- macrosomia (big baby) - reduced placental fx & possible meconium aspiration - dysfunctional labor from continued fetal growth - birth trauma (3rd-4th degree laceration) - shoulder dystocia

Trauma

- major cause is car accidents causing blunt force trauma, another cause is domestic violence & falls - may result in hemorrhage or separation of placenta, fractures/internal injuries - *treatment* → cardiopulmonary support, control bleeding, evaluate uterus/fetus

Preterm Premature Rupture of Membranes

- occurs b4 37 wks gestation - associated w/ preterm labor

Labor Dysfunction: Problems with Passage

- pelvis type - soft-tissue abnormalities

Placenta Previa

- placenta covers cervix - risk for hemorrhage if labor begins - vaginal exams contraindicated because NOTHING GOES IN

Umbilical Cord Prolapse

- prolapsed cord slips down after rupture of membranes & becomes compressed between fetus & pelvis - *s/s* → no visible cord hanging out, FHR drops - *interventions* → patient in knee-chest position, push fetal head straight up, provide counter-traction, so there is no cord ecclusion, hold baby's head until its born (NEVER put cord back in/touch the cord)

Labor Dysfunction: Problems with Psyche

- prolonged labor - precipitous labor - dysfunctional labor - maternal exhaustion

Uterine Inversion: Treatment

- replacement in ab cavity - maternal stabilization - hysterectomy if needed

Multifetal Pregnancy

- result in *uterine over distention* → hypotonic contractions, abnormal presentation, risk for postpartum hemorrhage & fetal hypoxia

Umbilical Cord Prolapse: Risk Factors

- ruptured membranes - fetus remaining at high station - fetus that poorly fits pelvic inlet (small, breeched, transverse lie - hydramnios

Most Common Pre-Term Risk Factors

- short cervical length ( < 25 mm) - previous preterm birth - positive fetal fibronectin (fFN) after 22 wks gestation

Dysfunctional Labor: Problems with Passenger

- shoulder dystocia, macrosomia - abnormal fetal position (face, OP, compound) - multifetal preg - fetal anomalies

Uterine Rupture

- tear in uterine wall - *CM* → maternal signs of shock (hypotension, tachycardia, pallor, diaphoresis, decreased urine output), ab pain, sense of tearing, chest/shoulder pain, abnormal FHR patterns, cessation of contractions, palpation of fetus outside uterus

Magnesium Sulfate

- tocolytic, prevents seizures - Ca2+ gluconate is antidote

Hypertonic Contractions

- uncoordinated, irregular, painful & ineffective, high uterine resting tone - usually occurs during latent phase - *treatment* → tocolytics, hydration

Uterine Inversion

- uterus turns inside out (partly or completely) - accompanied by *massive blood loss & hypovolemic shock, severe pelvic pain* - usually during *3rd stage* of labor - uncommon but potentially fatal → recovery promoting uterine contraction and maintenance of circulating bv

Hypotonic Contractions

- weak, infrequent, not effective - usually occurs in active phase - *treatment* → amniotomy, oxytocin, C-section

Macrosomia

- weighs > 4,000 g (8 lb 13 oz)

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

1 A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. Presence of a barrel chest and acrocyanosis

1 A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis, a bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is common in the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of respiratory distress syndrome.

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately."

1 A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that would indicate positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.

A nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching? 1. "I can begin abdominal exercises immediately." 2. "I need to notify the health care provider if I develop a fever." 3. "I can't lift anything heavier than my newborn for at least 2 weeks." 4. "I need to turn on my side and push up with my arms to get out of bed."

1 Abdominal exercises should not start immediately following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. The other options are appropriate instructions for the client following a cesarean delivery.

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum

1 After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The nurse is preparing to instruct a client in how to bathe a newborn. Which statement should the nurse include in the instruction? 1. "Begin with the eyes and face." 2. "Begin with the feet and work upward." 3. "Do the back side first, and then the front side." 4. "Start with the chest, move to the face, and then finish the rest of the body."

1 Bathing should start at the eyes and face, usually the cleanest area. Next the external ear and the area behind the ears are cleansed. The newborn's neck should be washed because formula, lint, or breast milk will often accumulate in the folds of the neck. Hands and arms are then washed. The newborn's legs are washed next, and the diaper area is washed last.

An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? 1. Palpate the clavicles for a fracture. 2. Auscultate the heart for a cardiac defect. 3. Blanch the skin for evidence of jaundice. 4. Perform Ortolani's maneuver for hip dislocation.

1 Because of the newborn infant's large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles or brachial plexus palsy or both. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. A cardiac defect would not be related to birth trauma, even though there is an increase in cardiac defects such as transposition of the great vessels in the LGA newborn infant. Jaundice would not be present initially. Hip dislocation is a congenital disorder and is not caused by birth trauma.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1 Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood coll

Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response? 1. "The medication provides pain relief during labor." 2. "The medication will help prevent any nausea and vomiting." 3. "The medication will assist in increasing the contractions." 4. "The medication prevents respiratory depression in the newborn infant."

1 Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. It does not relieve nausea, increase uterine contractions, or prevent respiratory depression in the newborn infant.

The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate? 1. Tremors 2. Bradycardia 3. Flaccid muscles 4. Extreme lethargy

1 Clinical symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.

The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant? 1. Presence of a cephalhematoma 2. Infant blood type of O negative 3. Birth weight of 8 pounds 6 ounces 4. A negative direct Coombs' test result

1 Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves and the blood is absorbed into the circulatory system. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus or newborn. The birth weight in option 3 is within the acceptable range for a term newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that no maternal antibodies are present on fetal erythrocytes.

A newborn infant is diagnosed with gastroesophageal reflux (GER), and the infant's mother asks the nurse to explain the diagnosis. On what description should the nurse plan to base the response? 1. Gastric contents regurgitate back into the esophagus. 2. The esophagus terminates before it reaches the stomach. 3. Abdominal contents herniate through an opening of the diaphragm. 4. A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.

1 GER is regurgitation of gastric contents back into the esophagus. Option 2 describes esophageal atresia. Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia.

An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action? 1. Elevates the gastrostomy tube 2. Tapes the gastrostomy tube to the bed linens 3. Attaches the gastrostomy tube to low suction 4. Connects the gastrostomy to the feeding pump

1 In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass into the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. The remaining options are incorrect. Taping the tube to the bed linens presents a risk of accidental removal. Attaching the tube to suction could disrupt the surgical repair site. Feedings are not initiated in the immediate postoperative period.

The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? 1. The mother bathes the newborn infant after a feeding. 2. The mother states that she would gather all supplies before the bath is started. 3. The mother states that she would never leave the newborn infant in the tub of water alone. 4. The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist.

1 It is not advisable to bathe a newborn infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the infant, bathing before feeding may be the best time. All other options are appropriate interventions in teaching the mother how to bathe a newborn.

The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure? 1. Immersing the newborn in water 2. Supporting the newborn's body during the bath 3. Ensuring that the water temperature is warm 4. Ensuring that the water temperature does not exceed 100° F

1 Newborn infants may be immersed in water after the umbilical stump has healed. The infant's body must be supported at all times during the bath. Water should be warm, not hot. A bath thermometer may be used to check the temperature of the water, which should not exceed 100° F. If a thermometer is not available, water that is comfortable when tested on the inside of the wrist or elbow is appropriate.

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? 1. At 1 minute after birth and 5 minutes after birth 2. Immediately at birth, 3 minutes after birth, and 10 minutes after birth 3. At 1 minute after birth, 5 minutes after birth, and 10 minutes after birth 4. At 1 minute after birth, after the cord is cut, and after the mother delivers the placenta

1 One of the earliest indicators of successful adaptation of the newborn is the Apgar score. This test is performed 1 minute after birth and again 5 minutes after birth.

A woman infected with the human immunodeficiency virus (HIV) has given birth to a normal-appearing infant, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates a need for further instruction? 1. "I'm going to breast-feed my baby starting right away." 2. "I need to wash my hands before and after bathroom use." 3. "My baby needs to be on antiviral medications for the next 6 weeks." 4. "I am going to contact some support groups listed in my take-home material to help me with everything I'll have to deal with when I get home."

1 Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding; therefore HIV-positive clients should be encouraged to bottle-feed their neonates. Frequent hand washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.

The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action? 1. Massage the uterus until firm. 2. Take the client's blood pressure. 3. Contact the health care provider (HCP). 4. Assess the amount of drainage on the peripad.

1 When uterine atony occurs, the initial nursing action would be to massage the uterus until it is firm. If this does not assist in controlling blood loss, then the nurse would contact the HCP. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1 Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

The nurse is monitoring a postpartum client who is at risk of developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, would support a diagnosis of postpartum endometritis? 1. Abdominal tenderness and chills 2. Increased perspiration and appetite 3. Maternal oral temperature of 100.2° F 4. Uterus two fingerbreadths below midline and firm

1 Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 2, 3, and 4 represent normal maternal physiological responses in the immediate postpartum period.

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

1 Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given in the question.

The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? 1. Make a loud, abrupt noise to startle the newborn. 2. Stimulate the ball of the foot of the newborn by firm pressure. 3. Stimulate the perioral cavity of the newborn infant with a finger. 4. Stimulate the pads of the newborn infant's hands by firm pressure.

1 The Moro reflex is elicited by placing the newborn on a flat surface and striking the surface or making a loud, abrupt noise to startle the newborn. The newborn assumes sharp extension and abduction of the arms with the thumbs and forefingers in a C position; this is followed by flexion and adduction to an "embrace" position (legs follow a similar pattern). The Moro reflex is present at birth and is absent by 6 months of age if neurological maturation is not delayed. A persistent response lasting more than 6 months may indicate a neurological abnormality. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.

A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? 1. Encourage the parents to touch their newborn. 2. Identify specific caregiving tasks that may be assumed by the parents. 3. Explain the equipment that is used and how it functions to assist their newborn. 4. Give the parents pamphlets that will help them understand their newborn's condition.

1 The best initial action to begin the attachment process and promote bonding is to encourage the parents to touch their newborn. The parents' initial need is to become acquainted with their newborn. Option 2 may be frightening to the parents because of the condition of the newborn and the unfamiliarity of high-risk newborn care practices. This option will be appropriate later, as the newborn's condition becomes stable. Option 3 is important but is not specific to parent-newborn bonding activities. Option 4 is inappropriate initially. Requiring parents to focus on pamphlets or literature does not enhance the parent-newborn bond.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1 The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraceptio

The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? 1. Document the findings. 2. Contact the health care provider. 3. Apply an oxygen mask to the newborn infant. 4. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.

1 The normal respiratory rate for a normal newborn is 30 to 60 breaths per minute. On assessment, if the nurse noted a respiratory rate of 50 breaths per minute, the nurse should document these findings because they are normal. Options 2, 3, and 4 are inappropriate or unnecessary nursing actions.

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? 1. "I should apply my antiembolism stockings after breakfast." 2. "I should avoid prolonged standing or sitting in one position." 3. "I should perform regularly scheduled exercise such as walking." 4. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

1 The nurse should instruct the client to apply antiembolism stockings before the client rises in the morning to prevent the venous congestion that will begin as soon as the mother gets up. Circulation can be improved with a regular schedule of activity, preferably walking, and the mother should be instructed to avoid prolonged standing or sitting in one position and avoid placing pillows under the knees because of the risk venous stasis in the lower extremities. The mother also should be encouraged to maintain a fluid intake of at least 2500 mL/day to prevent dehydration and consequent sluggish circulation.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1 The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

The nurse is caring for a newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL. How should the nurse interpret this laboratory value? 1. A normal value 2. Lower than normal 3. Higher than normal 4. Requiring health care provider notification

1 Total calcium levels are 7.0 to 12.0 mg/dL in a term infant younger than 1 week and 8.0 to 10.5 mg/dL in a child. Neonatal hypocalcemia is defined as a total serum calcium level of less than 7.0 mg/dL. If a newborn baby's calcium level is abnormal, the nurse should notify the health care provider.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

1 When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1, 2, 3, 4 Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1, 2, 3, 6 The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications.

Which instructions should a nurse provide to a client following delivery regarding care of the episiotomy site to prevent infection? Select all that apply. 1. Report a foul-smelling discharge. 2. Take a warm sitz baths three times a day. 3. Change the perineum pads three times a day. 4. Use warm water to rinse the perineum after elimination. 5. Wipe the perineum from front to back after voiding and defecation.

1, 2, 4, 5 Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineal area to prevent infection. The client should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The client also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.

A nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply. 1. Wear a supportive bra between feedings. 2. Avoid breast-feeding during the time of breast engorgement. 3. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. 4. Apply moist heat to both breasts for about 20 minutes before a feeding. 5. Massage the breasts gently during a feeding, from the outer areas to the nipples.

1, 3, 4, 5 During breast engorgement, the client should be advised to feed the infant frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have an easier time latching on if the client softens her breast and expresses her milk before a feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before a feeding. This can be done in the shower or with warm wet towels. During a feeding, it is helpful to massage the breast gently from the outer area to the nipple. This helps stimulate the let-down and flow of milk. The client should also be instructed to wear a supportive bra between feedings.

Which are modes of heat loss in the newborn? Select all that apply. 1. Radiation 2. Urination 3. Convection 4. Conduction 5. Evaporation

1, 3, 4, 5 The newborn can lose heat through radiation, convection, conduction, and evaporation. Heat is not lost through urination.

A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1. Massaging the uterus 2. Pushing gently on the uterus 3. Assisting the woman to urinate 4. Rechecking the uterus in 1 hour 5. Checking for a distended bladder 6. Calling the delivery room to schedule an abdominal hysterectomy

1, 3, 5 If the uterus is soft and spongy and is not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. The nurse would then check for a distended bladder and assist the woman to urinate. Pushing on an uncontracted uterus could invert the uterus, potentially causing massive hemorrhage and rapid shock. Waiting for 1 hour without intervention could result in bleeding. The health care provider will need to be notified if uterine massage is not helpful. Pharmacological measures may be necessary to maintain firm contraction of the uterus. An abdominal hysterectomy may need to be performed for massive hemorrhage that is uncontrollable. The question presents no data indicating that hemorrhage is a problem. Additionally, the nurse would not schedule an operative procedure.

Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply. 1. Grunting respirations 2. Presence of vernix caseosa 3. Heart rate of 190 beats/minute 4. Anterior fontanelle measuring 5.0 cm 5. Bluish discoloration of hands and feet 6. A yellow discoloration of the sclera and body

1, 3, 6 Grunting respirations is a sign of possible respiratory distress. The normal newborn heart rate is 100 to 160 beats/minute. The presence of a yellow discoloration could indicate newborn jaundice. Options 2, 4, and 5 are normal findings. The anterior fontanelle should measure 5 cm wide by 2-3 cm long.

The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the heart rate is within normal range if which heart rate is noted on assessment? 1. 80 beats/min 2. 90 beats/min 3. 130 beats/min 4. 180 beats/min

3 The normal heart rate for a newborn infant ranges from approximately 120 to 160 beats/min. Options 1 and 2 indicate bradycardia. Option 4 indicates tachycardia.

A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? 1. Positive for HIV 2. Indicates the presence of maternal infection 3. Indicates that the newborn will develop AIDS later in life 4. Positive for acquired immunodeficiency syndrome (AIDS)

2 A positive antibody test in a child younger than 18 months of age indicates only that the mother is infected because maternal immunoglobulin G antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months. A positive ELISA does not indicate true HIV infection or the development of AIDS, nor does it indicate that the newborn will develop AIDS later in life.

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? 1. Ambulating 2. Breast-feeding 3. Taking sitz baths 4. Arriving home and activities are increased

2 Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. The other options are incorrect.

The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

2 An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn.

A nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2 Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The other options are not risks that are specifically related to placenta previa.

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1. Ask the client to turn on her side. 2. Ask the client to urinate and empty her bladder. 3. Massage the fundus gently before determining the level of the fundus. 4. Ask the client to lie flat on her back, with her knees and legs flat and straight.

2 Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When performing fundal assessment, the woman is asked to lie flat on her back, with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at the lowest risk for development of postpartum thromboembolic disorders? 1. A 39-year-old woman who reports that she smokes 2. A 26-year-old woman with a family history of thrombophlebitis 3. A 37-year-old woman in her fourth pregnancy who is overweight 4. A 22-year-old woman with a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

2 Certain factors create a risk for the development of thromboembolic disorders. These include smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than three pregnancies, and women who have had a cesarean birth. From the options presented, a 26-year-old woman with a family history of thrombophlebitis is least likely to develop thromboembolic disorders in the postpartum period

The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note? 1. Lethargy 2. Irritability 3. Higher-than-normal birth weight 4. A greater-than-normal appetite when feeding

2 Characteristic behaviors of the newborn infant with fetal alcohol syndrome (FAS) are similar to those of the drug-exposed newborn infant. These behaviors include irritability, tremors, poor feeding, and hypersensitivity to stimuli. Newborn infants with FAS are smaller at birth and present with failure to thrive. Head circumference and weight are most affected (smaller head circumference and decreased weight).

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2 Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which indicates an early sign of excessive blood loss? 1. A temperature of 100.4º F 2. An increased pulse rate of 88 to 102 beats/min 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/min

2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4° F 2. An increase in the pulse rate from 88 to 102 beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/minute

2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz 4. Head circumference appropriate for gestational age

2 Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant.

A woman has a nursing diagnosis of risk for infection related to prolonged rupture of membranes. Appropriate nursing interventions are to A. Monitor for fetal bradycardia B. Assess maternal temperature every 4 hours C. Monitor the odor of the amniotic fluid D. Assess cervical change every hour

C. Monitor the odor of the amniotic fluid

The postpartum unit nurse is developing a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan? 1. Use a low-pitched voice to speak to the infant. 2. Encourage the mother to hold the infant when the infant cries. 3. Encourage the parents to allow the infant to sleep in the parental bed. 4. Encourage the mother to allow the nursing staff to care for the infant during her hospital stay until she is discharged.

2 Holding the infant close and allowing the infant to feel the warmth will initiate a positive experience for the mother and will console the infant. The use of a high-pitched voice and participating in infant care are additional methods of promoting parental-infant attachment. Infants should not be allowed to sleep in the parental bed. The parents require time alone as a couple. Additionally, the danger of suffocation of the infant exists if the infant is allowed to sleep between parents.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently.

2 Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should understand that how many ventilations per minute should be delivered to this neonate? 1. 20 to 40 breaths/min 2. 40 to 60 breaths/min 3. 70 to 80 breaths/min 4. 80 to 100 breaths/min

2 If the newborn is apneic or has gasping respirations after stimulation, or the heart rate is below 100 beats/min, positive pressure ventilation by bag and mask can be given. The anesthesia bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/min at pressures of 15 to 20 cm H2O.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.

2 If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony.

A nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates a need for further teaching? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2 In most cases, the client can continue to breast-feed with both breasts. If the affected breast is too sore, the client can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2 In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa.

When planning care for a postpartum client that plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? 1. Offer only one breast at each feeding. 2. Massage distended areas as the infant nurses. 3. Cleanse nipples with a mild antibacterial soap before and after infant feedings. 4. Express and discard milk from the affected breast at the first signs of mastitis.

2 Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. Soap should not be used on the nipples because of the risk of drying or cracking. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely.

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instructions? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2 Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response? 1. "Mastitis usually involves both breasts." 2. "Mastitis can occur at any time during breast-feeding." 3. "Mastitis usually is caused by wearing a supportive bra." 4. "Mastitis is most common for women who have breast-fed in the past."

2 Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. Mastitis is more common in mothers nursing for the first time and usually affects one breast. A supportive bra will not cause mastitis; however, constriction of the breasts from a bra that is too tight may interfere with the emptying of all the ducts and may lead to infection.

The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and should determine that the respiratory rate is normal if which respiratory rate is noted? 1. A respiratory rate of 20 breaths/min 2. A respiratory rate of 40 breaths/min 3. A respiratory rate of 70 breaths/min 4. A respiratory rate of 80 breaths/min

2 Normal respiratory rate varies from 30 to 60 breaths/min when the infant is not crying. Respirations should be counted for 1 full minute to ensure an accurate measurement because the newborn is a periodic breather. Observing and palpating respirations while the infant is quiet promote accurate data collection.

The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn? 1. 3 2. 5 3. 7 4. 10

2 One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2. Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation.

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statement by the client would indicate the need for further instructions? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

2 Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. Therefore HIV-positive clients should be encouraged to bottle-feed their neonates. Frequent handwashing is encouraged. Support groups and community agencies can be identified to assist clients with home care of the newborn infant, the impact of the diagnosis of HIV infection, and finding available financial resources. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for their first 6 weeks of life.

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? 1. Applying lotions to exposed newborn skin 2. Assessing skin integrity and fluid status of the newborn 3. Having minimal contact with the newborn to prevent stimulation 4. Advising the mother to limit the newborn's oral intake during phototherapy

2 Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Assessing skin integrity and fluid status of the newborn infant is an essential component of phototherapy. Lotions are not used to ensure the therapeutic effect of light exposure in subcutaneous tissue. Contact with the newborn infant is important. Adequate oral fluids are essential to prevent dehydration because diarrhea is a common side effect of therapy. In addition, safe care for the newborn infant during phototherapy requires shielding the eyes with a soft eye shield to prevent retinal damage, keeping the newborn's skin exposed except for the wearing of a diaper, and changing the newborn's position frequently.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction on the birth record.

2 Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.

A nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? 1. Selective placement of the infant 2. Periodic well-baby examinations 3. Phenylketonuria (PKU) testing at birth 4. Administration of an antibiotic for an umbilical cord staphylococcal infection

2 Primary prevention activities are actions that are designed to prevent a disease from occurring or to reduce the probability of occurrence of a specific illness. Periodic well-baby examinations focus on health education, nutrition, concerns related to adequate housing, recreation, and genetics. Selective placement of the infant is vague and does not provide any specific information. PKU testing at birth is an example of secondary prevention because it relates to early diagnosis and treatment. Option 4 identifies an actual treatment.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned with the presence of subinvolution if which occurs? 1. The presence of afterpains 2. Retained placental fragments from delivery 3. An oral temperature of 99.0° F following delivery 4. Increased estrogen and progesterone levels as noted on laboratory analysis

2 Retained placental fragments and infection are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. An oral temperature of 99.0° F after delivery and the presence of afterpains are expected findings following delivery. Option 4 is not a cause of subinvolution and is unrelated to the subject of the question.

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1. "You should avoid sexual intercourse for 2 weeks after administration of the vaccine." 2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." 3. "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." 4. "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

2 Rubella vaccine is a live attenuated virus that provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. Informed consent for rubella and varicella vaccination in the postpartum period includes information about possible side effects and the risk of teratogenic effects. The client should be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months (or as indicated by the health care provider) after administration of the vaccine. Abstinence from sexual intercourse is unnecessary. Heat or extreme changes in temperature have no effect on the person who has been vaccinated. The vaccine is not known to cause anaphylactic reactions.

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding? 1. A depressed anterior fontanel 2. A soft and flat anterior fontanel 3. An anterior fontanel measuring 1 cm 4. An anterior fontanel measuring 7 cm

2 The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat and may range in size from almost nonexistent to 4 to 5 cm across. It normally closes by 18 to 24 months of age. A depressed fontanel may indicate dehydration.

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

2 The mode of perinatal transmission of human immunodeficiency virus (HIV) to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. HIV-positive clients should be encouraged to bottle-feed their infants per the health care provider's prescription. Frequent hand-washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.

The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score? 1. 7 2. 9 3. 8 4. 10

2 The newborn has a score of 9 because his heart rate, respiratory effort, muscle tone, and reflex irritability all have a score of 2, with color having a score of 1 because of the acrocyanosis.

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen

2 The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems.

The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and should note that the heart rate is normal if which rate is noted? 1. A heart rate of 100 beats/min 2. A heart rate of 140 beats/min 3. A heart rate of 180 beats/min 4. A heart rate of 190 beats/min

2 The normal heart rate in a newborn is 110 to 160 beats/min. The other options are incorrect.

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis? 1. Palpate for pedal pulses. 2. Ask the client about pain in the calf area. 3. Assess for the presence of vaginal hematoma. 4. Ask the client to ambulate and assess for the presence of pain.

2 Thrombophlebitis is a potential complication in the postpartum period. The client with thrombophlebitis may experience pain in the calf. The remaining options would not determine the presence of thrombophlebitis. Palpating pulses assesses circulation. The presence of a hematoma does not indicate thrombophlebitis. The nurse should not ask the client to ambulate if thrombophlebitis is suspected.

The nurse is developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1. Administration of anticoagulants 2. Elevation of the affected extremity 3. Ambulation eight to ten times daily 4. Application of ice packs to the affected area

2 Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the affected lower extremity to improve venous return also may be recommended. Warm packs may be prescribed to be applied to the affected area to promote healing. There is usually no need for anticoagulants or anti-inflammatory agents unless the condition persists. Bed rest or limited activity may be prescribed depending on health care provider preference.

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? 1. Monitoring the vital signs 2. Palpating the uterine fundus 3. Auscultating the bowel sounds 4. Assessing the amount of drainage on the peripad

2 To assess uterine involution, the nurse would palpate the fundal height. Fundal height is measured in fingerbreadths or centimeters in relation to the umbilicus, and this measurement is used to assess the rate of uterine involution. Vital signs and the amount of drainage on the peripad do not indicate uterine involution. Bowel sounds, although they may be diminished in the postpartum period, are not helpful in assessing uterine involution.

The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? 1. Wrap the tape measure around the infant's head, and measure just below the eyebrows. 2. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows. 3. Place the tape measure under the infant's head at the base of the skull, and wrap around to the front just below the eyes. 4. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.

2 To measure head circumference, the nurse should place the tape measure under the infant's head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included. Options 1, 3, and 4 are incorrect methods to measure the head circumference.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

2, 3, 4, 5 Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. 1. Retinopathy 2. Hypoglycemia 3. Fractured clavicle 4. Hyperbilirubinemia 5. Congenital heart defect 6. Necrotizing enterocolitis

2, 3, 5 Any newborn weighing more than 4000 g at birth is defined as being large for gestational age (LGA). Because of their size, LGA infants are also at risk for hypoglycemia. LGA infants also have a higher incidence of birth injuries (fractured clavicle), asphyxia, and congenital anomalies (heart defect). Retinopathy is a disorder that affects the developing vessels of preterm infants. Hyperbilirubinemia is not an immediate risk related to LGA. Preterm birth is the most prominent risk factor in the development of necrotizing enterocolitis.

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How would the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used. Drag the text in the left column to the correct order in the right column. An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR) with 20 milliunits of oxytocin (Pitocin) infusing at 125 mL/hr. 1 A 12-hour post-cesarean section delivery of a gravida 3, para 3, who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 2 A 48-hour post-cesarean section delivery of a gravida 1, para 1, who reports not yet having a bowel movement since delivery and requests a stool softener. 3 A 24-hour post-vaginal delivery of a gravida 4, para 4, who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen (Motrin).

2, 4, 1, 3 The 12-hour post-cesarean section delivery client should be assessed first because she is reporting a sensation of wetness; this could be excessive bleeding. The 24-hour post-vaginal delivery client is complaining of pain, which can be treated easily with oral medications; therefore this client should be assessed next. The 8-hour post-vaginal delivery client who is scheduled for a bilateral tubal ligation has an IV infusing of oxytocin, which will facilitate uterine involution, thereby promoting uterine contractions and minimal bleeding. A baseline assessment must be conducted preoperatively for a bilateral tubal ligation; however, the scheduled operative time is 5 hours away. The client who had cesarean section delivery 48 hours ago is assessed last as she is the farthest out from delivery, and the effectiveness of a stool softener will be achieved over time with continued administration.

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? 1. Lethargy 2. Sleepiness 3. Constant crying 4. Cuddles when being held

3 A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? 1. Determine Apgar score. 2. Auscultate the heart rate. 3. Thoroughly dry the newborn. 4. Take the newborn's rectal temperature.

3 An optimal thermal environment is essential to the effective care of a neonate. If a newborn is not thoroughly dried and placed in a warm environment immediately after delivery, cold stress may result. Infants respond to cold stress through an increased need for oxygen and depletion of glucose stores, resulting in an increased respiratory rate and possibly cyanosis. Although auscultating the heart rate is essential in the initial assessment of the newborn, palpating the heart rate via the umbilical cord can be done while drying the infant. Drying the infant should only take a few seconds and auscultating the heart rate can be done immediately afterward. The Apgar score is assessed at 1 and 5 minutes of life. Taking the temperature is not a priority immediately following delivery.

Which newborn is most at risk for a brachial plexus injury? 1. A term infant with a history of a forceps-assisted delivery 2. A term infant delivered via primary cesarean section for malpresentation 3. A large for gestational age infant with a history of shoulder dystocia at delivery 4. A 36-week preterm infant delivered vaginally after preterm rupture of membranes

3 Brachial plexus injuries, a fractured clavicle, or a fractured humerus are all possible risks during a delivery of an infant with shoulder dystocia and must be considered during the immediate newborn assessment. Stretching or pulling away of the shoulder from the head may occur during a difficult delivery such as one involving shoulder dystocia. This positioning may cause damage to the upper plexus. Larger infants are more likely to be involved in a delivery in which inadequate space is a concern. In most cases, option 4 would result in an infant of smaller size, so shoulder dystocia would not be a priority risk. Shoulder dystocia does not occur during cesarean section, which eliminates option 2. Option 1 can be eliminated because with a forceps delivery, priority concern is for facial or head injuries more than shoulder, arm, or clavicle injuries.

A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action? 1. Reinforce the dressing. 2. Document the findings. 3. Contact the health care provider. 4. Swab the drainage and send the sample to the laboratory for culture.

3 Complications after circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs of infection occur, the health care provider is notified. The nurse would change, not reinforce, the dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical site. The nurse would document the findings, but this is not the priority item. The health care provider will prescribe a culture if it is necessary; it is not within the realm of nursing responsibilities to prescribe a diagnostic test.

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3 Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).

Which would be considered a normal finding in a newborn less than 12 hours old? 1. Grunting respirations 2. Heart rate of 190 beats/min 3. Bluish discoloration of the hands and feet 4. A yellow discoloration of the sclera and body

3 Having bluish hands and feet is termed acrocyanosis and is a normal finding in the newborn. Grunting respirations is a sign of possible respiratory distress and the normal newborn heart rate is 100 to 160 beats/min. A yellow discoloration of the sclera and skin indicates jaundice.

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

3 Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. Evaporation of moisture from a wet body surface dissipates heat along with the moisture.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position.

3 If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day? 1. 100 2. 300 3. 500 4. 1000

3 If the client is breast-feeding, her calorie needs increase by approximately 500 cal/day. The client should also be instructed regarding the need for increased fluids and the need for prenatal vitamins and iron supplements.

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? 1. "I should retract the foreskin and clean the penis every time I change the diaper." 2. "I need to retract the foreskin and clean the penis every time I give my infant a bath." 3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

3 In male newborn infants, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother should be told to allow separation to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning. Options that identify actions that address retraction of the foreskin are therefore incorrect.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1. Pump both breasts and discard the milk. 2. Bottle-feed the infant on a temporary basis. 3. Breast-feed from the left breast and gently pump the right breast. 4. Stop breast-feeding from both breasts until this condition resolves.

3 In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breast, breast-feeding will need to be discontinued and a pump should be used to empty the breast (but the milk should be discarded). Options 1, 2, and 4 are incorrect.

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate? 1. Massage the fundus. 2. Contact the health care provider. 3. Cover the client with a warm blanket. 4. Place the client in Trendelenburg's position.

3 In the postpartum period, a woman may experience a shaking, uncontrollable chill immediately after birth. The exact cause of this fairly common event is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The appropriate nursing action would be to provide a warm blanket to the client and a warm drink if this is not contraindicated.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive

3 Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.

A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's health care provider needs to be notified of the finding.

3 Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4 are incorrect.

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Notify the health care provider. 4. Cover the ears with gauze pads.

3 Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although the findings should be documented, the most appropriate action would be to notify the health care provider. Options 2 and 4 are inaccurate and inappropriate nursing actions.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider. 4. Encourage increased oral intake of fluids.

3 Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes an Apgar score of 6. On the basis of this score, what should the nurse determine? 1. The newborn requires vigorous resuscitation. 2. The newborn is adjusting well to extrauterine life. 3. The newborn requires some resuscitative interventions. 4. The newborn is having some difficulty adjusting to extrauterine life.

3 One of the earliest indicators of successful adaptation of the newborn to extrauterine life is the Apgar score. Scoring ranges from 0 to 10. A score of 8 to 10 indicates that the newborn is adjusting well to extrauterine life. A score of 5 to 7 often indicates that the newborn requires some resuscitative interventions. Scores of less than 5 indicate that the newborn is having difficulty adjusting to extrauterine life and requires vigorous resuscitation.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided.

3 Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.

A nurse is monitoring the client for signs of postpartum depression. Which would indicate the need for further assessment related to this form of depression? 1. The client is caring for the infant in a loving manner. 2. The client demonstrates an interest in the surroundings. 3. The client constantly complains of tiredness and fatigue. 4. The client looks forward to visits from the father of the newborn.

3 Postpartum depression is not the normal depression that many new mothers experience from time to time. The client experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The client also is unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The client often expresses a sense of loss of self. Generalized fatigue, complaints of ill health and difficulty in concentrating also are present. The client would have little interest in food and experience sleep disturbances.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, would indicate the need for further assessment related to this form of depression? 1. The mother is caring for the infant in a loving manner. 2. The mother demonstrates an interest in the surroundings. 3. The mother constantly complains of tiredness and fatigue. 4. The mother looks forward to visits from the father of the newborn.

3 Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and would experience sleep disturbances.

A postpartum care unit nurse is reviewing the records of 4 new mothers admitted to the unit. The nurse determines that which mother would be least likely at risk for developing a puerperal infection? 1. A mother who had ten vaginal exams during labor 2. A mother with a history of previous puerperal infections 3. A mother who gave birth vaginally to a 3200 gram infant 4. A mother who experienced prolonged rupture of the membranes

3 Risk factors associated for puerperal infection include a history of previous puerperal infections, cesarean births, trauma, prolonged rupture of the membranes, prolonged labor, multiple vaginal exams, and retained placental fragments.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2. Reinforce the dressing. 3. Document the findings. 4. Contact the health care provider (HCP).

3 The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the health care provider. Because the findings identified in the question are normal, the nurse would document the assessment findings.

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation? 1. Sunlight for 3 days 2. Scratching the injection site 3. Pregnancy for 2 to 3 months after the vaccination 4. Sexual intercourse for 2 to 3 months after the vaccination

3 Rubella vaccine is a live attenuated virus that evokes an antibody response, which provides immunity for 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months after receiving the vaccine. Sunlight has no effect on the client who is vaccinated. The vaccine may cause local or systemic reactions, but all of these are mild and short-lived. Abstinence from sexual intercourse is not necessary unless another form of effective contraception is not being used.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, would indicate a complication related to a laceration of the birth canal? 1. Presence of dark red lochia 2. Palpation of the uterus as a firm contracted ball 3. The saturation of more than one peripad per hour 4. Palpation of the fundus at the level of the umbilicus

3 Saturation of more than one peripad per hour is considered excessive even in the early postpartum period. In the first 24 hours after birth, the uterus will feel like a firmly contracted ball, roughly the size of a large grapefruit. One easily can locate the uterus at the level of the umbilicus. Lochia should be dark red and moderate in amount.

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? 1. Elevate her legs. 2. Remain on bed rest. 3. Ambulate frequently. 4. Apply warm, moist packs to the legs.

3 Stasis is believed to be a predisposing factor in the development of thrombophlebitis. Because cesarean delivery is also a risk factor for thrombophlebitis, new mothers should ambulate early and frequently to promote circulation and prevent stasis. The other options may be interventions for the client diagnosed with thrombophlebitis. Additionally, bed rest promotes stasis.

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The unit nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client? 1. Postpartum infection 2. Maternal attachment 3. Maternal overexertion 4. Postpartum newborn-mother bonding

3 The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Although options 1, 2, and 4 are appropriate nursing concerns during the postpartum period, the primary concern for the cardiac client is to maintain a safe environment because of the potential for cardiac compromise.

The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1. Urinary output 2. Total bilirubin levels 3. Blood glucose levels 4. Hemoglobin and hematocrit levels

3 The most common metabolic complication in the SGA newborn infant is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest-priority action, because the post-term SGA infant is typically dehydrated as a result of placental dysfunction. Hemoglobin and hematocrit levels are monitored because the post-term SGA infant exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1. Call the health care provider. 2. Assess the client's vital signs. 3. Gently message the uterine fundus. 4. Administer a 300-mL bolus of a 20 units/L oxytocin (Pitocin) solution.

3 The most frequent cause of excessive bleeding after childbirth is uterine atony. A major intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. Options 1, 2, and 4 may be necessary but they are not initial actions. The initial action is to alleviate the problem. Additionally a health care provider's prescription is needed to administer a medication.

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction? 1. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my health care provider." 2. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis." 3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." 4. "I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings."

3 The mother should not discontinue breast-feeding even if mastitis occurs. Mastitis, a breast infection, is best characterized by a sudden onset of flulike symptoms, localized breast pain and tenderness, and a hot, reddened area on the breast that often resembles the shape of a pie wedge. Treatment usually includes antibiotics, but the mother should be instructed to feed the baby or pump frequently to adequately empty the affected breast.

The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? 1. Thin and gelatinous, with increased subcutaneous fat 2. Thin and gelatinous, with increased amounts of brown fat 3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat 4. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat

3 The skin of a newborn infant plays a significant role in thermoregulation and as a barrier against infection. The skin of a preterm newborn infant is immature in comparison with that of a term newborn infant. The skin of a preterm newborn is thin and gelatinous, with decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborn infants lose heat because of their large body surface area in relation to their weight and because their posture is more relaxed, with less flexion. Therefore preterm newborn infants are less able to generate heat, which places them at risk for increased heat loss and increased fluid requirements

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse should expect to observe which finding? 1. One artery 2. Two veins 3. Two arteries 4. One artery and one vein

3 The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. There should be no odor noted from the umbilical cord. Options 1, 2, and 4 are incorrect.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3 Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

The nursing student is assigned to care for a client in the postpartum unit. The coassigned nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? 1. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." 2. "I should ask the client to keep a record and document every time the perineal pad is changed." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

3 To gather accurate data for comparison, the perineal pads must be weighed both before and after use. Once these weights are gathered, the amount of lochia flow can be accurately determined. Noting the time frame between pad changes and the number of pads used also is an important factor. Gauging the amount of staining does not provide accurate data. Asking the client to obtain the information also may not provide accurate data.

Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route? 1. Erythromycin 2. Tetracycline 1% 3. Phytonadione (Vitamin K) 4. Measles-mumps-rubella vaccination

3 Vitamin K is administered intramuscularly into the vastus lateralis muscle. Tetracycline 1% and erythromycin are prescribed for prophylaxis against gonorrhea and are administered into the eye. The measles-mumps-rubella vaccination is not given to a newborn.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client? 1. Apply a heating pad to breasts for comfort. 2. Wear a breast shield to correct nipple inversion. 3. Wear a supportive brassiere continuously for 72 hours. 4. Use the manual breast pump provided to express milk.

3 Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant sucking) or increase in circulation (heating pad) will increase milk production or cause the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be necessary if the mother chooses not to breast-feed her infant.

A client who is a gravida III, para III had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a level of 6 on pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used. Drag the text in the left column to the correct order in the right column. Prenatal vitamin 1 tablet orally daily 1 Docusate sodium (Colace) 100 mg orally 2 Ketorolac (Toradol) 30 mg by intravenous push over 3 minutes 3 Ampicillin sodium (Ampicillin) 1 g intravenous (IV) piggyback over 60 minutes

3, 4, 2, 1 The client is complaining of abdominal cramping, which is the priority and should be treated first; an IV route (ketorolac) is used because it will alleviate the pain rapidly. The risk of infection is greater than the need for a stool softener or a multivitamin; therefore, the IV antibiotic is administered next. The client who has not had her first bowel movement and is afraid to do so is the next priority; therefore, the docusate sodium would be administered next. The multivitamin requires daily administration and works over time to assist in replenishing the nutrients lost during blood loss associated with the surgery; this would be administered last.

The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? 1. A suture split greater than 1 cm 2. A hard, rigid, immobile suture line 3. Swelling of the soft tissues of the head and scalp 4. Edema resulting from bleeding below the periosteum of the cranium

4 A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely to be caused by ruptured blood vessels from head trauma during birth. The lesion develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 may indicate increased intracranial pressure. Option 2 may be associated with premature closure or craniosynostosis and should be investigated further. Option 3 identifies a caput succedaneum.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4 A client with a urinary tract infection must be encouraged to take the medication for the entire time it is prescribed. The client should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged.

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which nursing intervention is least appropriate in assisting the promotion of mother-infant interaction and bonding? 1. Accepting the client's feelings 2. Acknowledging the client's apprehension 3. Assisting the client with giving the baths to allow her to become more at ease 4. Leaving the infant with the client so that she will be required to provide the care

4 A client with no experience of handling infants may be fearful and reluctant to handle her newborn or to take on physical care on her own. Leaving the infant with the mother so that she will be required to provide the care will produce additional apprehension. Acceptance of her feelings and acknowledgment of the apprehension can help an unsure mother begin to participate in caring for her newborn. Assistance will help the client become more at ease.

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/min. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, what is the nurse's next action? 1. Reassure the client. 2. Monitor fundal height. 3. Apply perineal pressure. 4. Prepare the client for surgery.

4 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type . The use of an epidural, prolonged second-stage labor, and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 mL of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action is to prepare the client for surgery to stop the bleeding.

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? 1. "I will probably need my mother to help me with housekeeping." 2. "Because I am so sore, I will nurse the baby while lying on my side." 3. "My husband and I will not have intercourse until the stitches are healed." 4. "The only medications I will take are prenatal vitamins and stool softeners."

4 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type. The postoperative client will need an antibiotic because she is at increased risk for infection as a result of the break in skin integrity and collection of blood at the hematoma site. Stating that she will need only prenatal vitamins and stool softeners indicates that she requires further teaching. All other options indicate that the mother understands the home care measures after surgical evacuation and repair of a paravaginal hematoma.

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique would assist to support the newborn's diagnosis? 1. Monitoring the urine for blood 2. Monitoring the urinary output pattern 3. Testing for contractures of the extremities 4. Stimulating for reflex responses in the extremities

4 A subdural hematoma can cause pressure on a specific area of the cerebral tissue. Especially if the infant is actively bleeding, such pressure can cause changes in the stimuli responses in the extremities on the opposite side of the body. Options 1 and 2 are incorrect. An infant after delivery normally would be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. Option 3 is incorrect because contractures would not occur this soon after delivery.

An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? 1. Hepatitis B vaccine given within 24 hours after birth 2. Immune globulin (IG) given as soon as possible after delivery 3. Hepatitis B immune globulin (HBIG) given within 14 days after birth 4. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

4 Both HBIG and the vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve lifelong prophylaxis; they are administered within 12 hours after birth. IG is given to prevent hepatitis A.

The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant? 1. Excessive oral secretions 2. Bowel sounds heard over the chest 3. Hiccups and spitting up after a meal 4. Coughing, wheezing, and short periods of apnea

4 Clinical manifestations associated with hiatal hernia specifically include vomiting, coughing, wheezing, short periods of apnea, and failure to thrive. Excessive oral secretions are a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Bowel sounds heard over the chest is a clinical manifestation associated with congenital diaphragmatic hernia. Hiccups and spitting up after a meal is a clinical manifestation of gastroesophageal reflux.

A postpartum unit nurse is preparing to care for a client who has just delivered a healthy newborn. In the immediate postpartum period what is the recommended frequency for the nurse to assess the client's vital signs? 1. Every hour for the first 2 hours and then every 4 hours 2. Every 30 minutes during the first hour and then every hour for the next 2 hours 3. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4. Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours

4 During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

A nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis? 1. A primigravida with a normal spontaneous vaginal delivery 2. A gravida II who delivered vaginally following an 18-hour labor 3. A client experiencing an elective cesarean delivery at 38 weeks' gestation 4. An adolescent experiencing an emergency cesarean delivery for fetal distress

4 Endometritis is an acute infection of the uterine mucous lining immediately after delivery and is still a leading cause of mortality for childbearing women in the United States. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. The other options do not describe the client most at risk to develop endometritis following delivery.

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.

4 Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for administering this medication to a newborn infant.

The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern.

4 Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after delivery. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are inappropriate interventions.

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instructions? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4 Foods and fluids that acidify, not alkalinize the urine should be encouraged. The woman should be encouraged to urinate frequently throughout the day, instructed to take the medication for the entire time it is prescribed, and encouraged to drink at least 3000 mL of fluid each day to flush the infection from the bladder.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feeding. 2. The mother holds the newborn properly during feeding and burping. 3. The mother tests the temperature of the formula before initiating feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

4 Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.

4 If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor

4 Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Cover the ears with gauze pads. 4. Notify the health care provider (HCP).

4 Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appropriate action would be to notify the HCP. The remaining options are inaccurate and inappropriate nursing actions.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast-feeding." 4. "I should wash my nipples daily with soap and water."

4 Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand-washing and that she should breast-feed every 2 to 3 hours.

Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1. Peripads 2. Tape measure 3. Reflex hammer 4. Blood pressure cuff

4 Methylergonovine is an oxytocic agent used to prevent or control postpartum hemorrhage by contracting the uterus. It causes constant uterine contractions and may cause the blood pressure to elevate. A priority assessment before administering this medication is obtaining a baseline blood pressure. The client's blood pressure also should be monitored during the administration of the medication. Methylergonovine is administered cautiously in the presence of hypertension, and the health care provider should be notified if hypertension occurs. The items in options 1, 2, or 3 are not priority items.

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? 1. Initiate an intravenous (IV) line on the newborn infant. 2. Place the newborn infant on a cardiorespiratory monitor. 3. Place the newborn infant in the radiant warmer incubator. 4. Administer oxygen via resuscitation bag to the newborn infant.

4 Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation. The immediate nursing action should be to administer oxygen via resuscitation bag. Although the newborn infant may require a cardiorespiratory monitor and an IV line and may need to be placed in a radiant warmer incubator, the initial action of the nurse should be to provide resuscitative measures.

Which nursing intervention would be most appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? 1. Limit fluid intake. 2. Maintain the client in a supine position. 3. Ask family members to care for the newborn. 4. Encourage the client to take pain medication as prescribed.

4 Nursing responsibilities for the care of the client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler's position to facilitate drainage and lessen congestion, providing appropriate analgesia to lessen the pain, and administering antibiotics as prescribed. If the client's pain is relieved, she will be more likely to participate in newborn care. Asking family members to care for the newborn will not facilitate client participation in newborn care.

The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition? 1. Inside the abdominal cavity and under the skin 2. Inside the abdominal cavity and under the dermis 3. Outside the abdominal cavity and not covered with a sac 4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane

4 Omphalocele is an abdominal wall defect. It involves a large herniation of the gut into the umbilical cord. The viscera are outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane. Options 1 and 2 describe an umbilical hernia. Option 3 describes a gastroschisis.

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score? 1. 3 2. 5 3. 7 4. 10

4 One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 beats/min = 1; greater than 100 beats/min = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well-flexed = 2. Irritability or reflexes (measured by response to bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2.

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "It's OK to allow the unlicensed assistive personnel to carry my newborn to the nursery." 4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."

4 Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking the nurse to attend to the newborn if the mother is napping and no family member is available to watch the newborn (the newborn is never left unattended). If the mother states that she will ask the nurse to watch the newborn while she is sleeping, she has understood the teaching. Options 1, 2, and 3 are incorrect and would indicate that the mother needs further teaching.

The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis? 1. Afterpains 2. Increased estrogen levels 3. Increased progesterone levels 4. Retained placental fragments from delivery

4 Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. Options 2 and 3 are not causes of subinvolution.

The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which response made by the student indicates an understanding of this phase? 1. "The client would be independent." 2. "The client initiates activities on her own." 3. "The client participates in mothering tasks." 4. "The client is self-focused and talks to others about labor."

4 Rubin has identified three phases of regeneration during the postpartum period. The taking-in phase occurs in the first 3 days postpartum, and the taking-hold phase occurs between days 3 to 10. During the taking-in phase, the new mother is attempting to integrate her labor and birth experience. She tends to need sleep and feels fatigued, talks about labor, and is self-focused and dependent. In the taking-hold phase, the client is more active, independent, initiates activities, and partakes in mothering tasks. In the letting-go phase, the mother may grieve over the separation of the baby from part of her body.

The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which finding? 1. Loose stools 2. High-pitched cry 3. Vigorous feeding habits 4. A copper-colored skin rash

4 Signs and symptoms of congenital neonatal syphilis may be nonspecific initially, including poor feedings, slight hyperthermia, and "snuffles." By the end of the first week of life, a copper-colored maculopapular dermal rash typically is observed on the palms of the hands, on the soles of the feet, in the diaper area, and around the mouth and anus. Options 1, 2, and 3 are not associated signs of this disorder.

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? 1. "If I experience any sweating during the night, I should call the health care provider." 2. "If I have uterine cramping while breast-feeding, I should contact the health care provider." 3. "If I'm still having bloody vaginal drainage in a week, I should contact the health care provider." 4. "If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider."

4 Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these symptoms occur, the client needs to contact the HCP. Options 1, 2, and 3 are normal changes that occur in the postpartum period.

A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? 1. A rectal thermometer 2. A blood pressure cuff 3. A specific gravity urinometer 4. A bottle of sterile normal saline

4 Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. The newborn with spina bifida is at risk for infection before the closure of the sac, which is done soon after birth. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site. A thermometer will be needed to assess temperature, but in this newborn the priority is to maintain sterile normal saline dressings over the sac. Blood pressure may be difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the health care provider (HCP).

4 Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the HCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition.

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4 The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than the other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 3 that present the risk for hemorrhage.

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? 1. Lack of power about the situation 2. Grieving because of the loss of the baby 3. Lack of knowledge regarding what occurred 4. Concern about the loss of the baby and personal health

4 The client expresses that there is no way out of the situation except for death; therefore the client exhibits concern about the loss of the baby and personal health. The data given do not support lack of power. Grieving is a possible client problem at a later time; however, at this time, the concern over the loss should take priority. Lack of knowledge is a possible problem later, but not enough data support it at this point, and it is not the priority.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.

4 The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? 1. "The cord will fall off in 1 to 2 weeks." 2. "Alcohol may be used to clean the cord." 3. "I should cleanse the cord two or three times a day." 4. "I need to fold the diaper above the cord to prevent infection."

4 The diaper should be folded below the cord to keep urine away from the cord, so a statement by the client that the diaper should be folded above the cord would be incorrect, indicating the need for further instruction. The cord should be kept clean and dry to decrease bacterial growth. Cord care is required until the cord dries up and falls off, between 7 and 14 days after birth. The cord should be cleansed two or three times a day with soap and water or other prescribed agents.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instructions? 1. "I need to take the antibiotics as prescribed." 2. "I need to take warm sitz baths to promote healing." 3. "I need to apply warm compresses to provide comfort." 4. "I need to isolate the infant for 48 hours after beginning the antibiotics."

4 The infant is not isolated routinely from the mother with a wound infection, but the mother must be taught good hand washing techniques and how to protect the infant from contact with contaminated articles. If the mother has a wound infection, broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort in the area.

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant? 1. The mother has cracked nipples and feeds the infant with a supplemental bottle. 2. The mother complains of breast engorgement, and the infant demonstrates difficulty in latching onto the breast. 3. The mother is breast-feeding the infant with the infant's head turned toward her breast and the body flat in her arms; the mother has sore nipples, and the infant has a suck blister. 4. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

4 The infant should be positioned completely facing the mother with head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. The infant's head turned toward the breast and the body flat in the mother's arms is incorrect because it demonstrates improper positioning. Breast engorgement, sore nipples, and cracked nipples are all complications that are the result of improper positioning.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1. The mother is observed talking to the newborn. 2. The mother performs cord care for the newborn. 3. The mother verbalizes discomfort with the new role of motherhood. 4. The mother requests that the nurse feed the newborn because she is feeling fatigued.

4 The nurse should be alert to maladaptive interaction in the maternal-infant bonding processes. If the nurse notes that the mother is avoiding interaction with the newborn or is avoiding caring for the newborn, the nurse should suspect the potential for a maladaptive interaction. Talking to the newborn or willingness to perform cord care does not indicate a maladaptive response. Expressing discomfort with the new role of motherhood is a normal, expected process, and it is important for the mother to verbalize concerns.

The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select? 1. The gluteal muscle 2. The lower aspect of the rectus femoris muscle 3. The medial aspect of the upper third of the vastus lateralis muscle 4. The lateral aspect of the middle third of the vastus lateralis muscle

4 The preferred injection site for vitamin K in the newborn infant is the lateral aspect of the middle third of the vastus lateralis muscle in the infant's thigh. This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.

The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant? 1. 10 to 20 mL 2. 30 to 90 mL 3. 75 to 100 mL 4. 90 to 150 mL

4 The stomach capacity is 10 to 20 mL for a newborn infant, 30 to 60 mL for a 1-week-old infant, 75 to 100 mL for a 2- to 3-week-old infant, and 90 to 150 mL for a 1-month-old.

A postpartum client with deep vein thrombosis is being treated with anticoagulant therapy. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for which symptoms? 1. Dysuria, ecchymosis, and vertigo 2. Epistaxis, hematuria, and dysuria 3. Hematuria, ecchymosis, and vertigo 4. Hematuria, ecchymosis, and epistaxis

4 The treatment for deep vein thrombosis is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

A nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. The nurse plans to explain to the parents that which is the purpose of the medication? 1. Help the newborn to see more clearly. 2. Ensure the sterility of the conjunctiva in the newborn. 3. Guard against infection acquired during intrauterine life. 4. Protect the newborn from contracting an eye infection during birth.

4 The use of eye prophylaxis with an agent such as erythromycin protects the newborn from contracting a conjunctival infection during birth. This infection, called ophthalmia neonatorum, results from maternal vaginal infection with chlamydia or gonorrhea. This prophylaxis is mandatory in the United States. Options 1, 2, and 3 do not describe the purposes of this medication.

The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

4 Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn to prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K-deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.

The postpartum unit nurse has provided information regarding performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that the sitz bath will promote which action? 1. Numb the tissue. 2. Stimulate a bowel movement. 3. Reduce the edema and swelling. 4. Assist in healing and provide comfort.

4 Warm, moist heat is used after the first 24 hours after tissue trauma from a vaginal birth to provide comfort and promote healing and reduce the incidence of infection. This warm, moist heat is provided via a sitz bath. Ice is used in the first 24 hours to reduce edema and numb the tissue. Promoting a bowel movement is best achieved by ambulation.

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant? 1. Massage the breasts, applying gentle pressure on the areolas with the thumb and forefinger. 2. Have the mother grasp her areola between the thumb and forefinger and tug firmly to get the nipple to protrude. 3. Encourage taking a cool shower, allowing the water to run over the breasts, because this will encourage the nipples to protrude. 4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

4 Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn infant to grasp the nipple. Massaging the breast is an appropriate instruction for the mother with engorgement but will not help with resolving inverted nipples. True inverted nipples will retract if the areola is pressed between the thumb and forefinger. Having the client take a cool shower will only make the mother cold, and it has no effect on inverted nipples.

The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. 1. Call bell 2. Feeding pump 3. Vital sign machine 4. Phototherapy lights 5. Intravenous (IV) pump

4, 5 Given the fact that the newborn is 4 days old, accurate delivery and prevention of circulatory overload is a priority. The IV fluid rate must be maintained using an IV pump. Fluids by gravity would not be the safest mode of delivery in a newborn. The phototherapy lights must be used continually to be effective. The newborn can be fed via gravity using the gavage method if necessary. Vital signs may be obtained without powered equipment. The caregiver may require a call bell, but there are other options for a call device, such as a hand-held noisemaker or whistle.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.

4, 5, 6 Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

A woman is 6 cm dilated. Her labor had been progressing as expected until about 2 hours ago. At that time she stated that the contractions were not as painful, the nurse noted the abdomen was easy to indent. A vaginal exam showed no progression of dilation in 2 hours. Some nursing measurers to help correct hypotonic contractions are to increase fluid intake and A. Assist her to walk B. Request an epidural C. Administer pain medication D. Assist her to her side and have her lie in that position for the next hour

A. Assist her to walk

A hospitalized woman in preterm labor is being given magnesium sulfate intravenously. The expected outcome for this treatment will be met if A. Labor contractions are suppressed B. Newborn's lungs begin to produce surfactant C. Seizures do not occur D. Membranes remain intact

A. Labor contractions are suppressed

The nurse should assist the laboring woman into hands-and-knees position when: A. the occiput of the fetus is in a posterior position B. the fetus is at or above the ischial spines C. the fetus is in a vertex presentation D. the membranes rupture

A. the occiput of the fetus is in a posterior position

1. The nurse is discussing infant care as part of the mother-infant's couplet discharge planning. The mother asks the nurse "When will my baby's cord fall off?" The nurse responds, "Your baby's cord should fall off by _______________ after birth."

ANS: 2 weeks Cord separation is influenced by several factors, including type of cord care, type of birth and other perinatal events. The average cord separation time is 10 to 14 days. Some dried blood may be seen at the umbilicus after separation.

1. Nurses need to know that when any woman is admitted to the hospital and is _____ to _____ weeks pregnant, she should receive antenatal glucocorticoids unless she has chorioamnionitis. Because these drugs require a 24-hour period to become effective, timely administration is essential.

ANS: 24; 34 All women between 24 and 34 weeks of gestation who are at risk for preterm birth within 7 days should receive treatment with a single course of antenatal glucocorticoids.

2. The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infant's risk of hypoglycemia. The nurse becomes concerned if the infant's blood glucose concentration falls below ______ mg/dl.

ANS: 40 If the newborn has a blood glucose level below 40 mg/dl intervention such as breastfeeding or bottle-feeding should be instituted. If levels remain low after this intervention an intravenous with dextrose may be warranted.

2. __________ is defined as long, difficult, or abnormal labor. It is caused by various conditions associated with the five factors affecting labor.

ANS: Dystocia A dysfunctional labor may result from problems with the powers of labor, the passenger, the passage, the psyche or a combination of these.

1. The acronym ________ is used as a reminder that the site of an episiotomy or perineal laceration should be assessed for five physical signs.

ANS: REEDA The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge, and approximation (the edges of the wound should be close). If redness is accompanied by pain or tenderness, this may indicate infection. Edema may illustrate soft tissue damage and delay wound healing. There should be no discharge. The edges of the wound should be closely approximated as if held together by glue.

3. A nurse is caring for a patient in the active phase of labor. The woman's BOW spontaneously ruptures. Suddenly the woman complains of dyspnea and appears restless and cyanotic. Additionally, she becomes hypotensive and tachycardic. The nurse immediately suspects the presence of a(n) _____________.

ANS: amniotic fluid embolism Anaphylactoid syndrome of pregnancy (ASP) is more commonly known as amniotic fluid embolism. This is a rare but devastating complication of pregnancy. It is characterized by the sudden, acute onset of hypoxia, hypotension or cardiac arrest, and coagulopathy. ASP can occur during labor, birth, or within 30 minutes after birth. This clinical presentation is similar to that observed in patients with anaphylactic or septic shock. In both of these conditions, a foreign substance is introduced into the circulation.

3. A ________ succedaneum may appear over the vertex of the newborn's head as a result of pressure against the mother's cervix while in utero.

ANS: caput This pressure causes localized edema and appears as an edematous area on the infant's head. The edema may cross suture lines, is soft to the touch, and varies in size. It usually resolves quickly and disappears entirely within the first few days after birth. Caput may also occur as the result of an operative delivery when a vacuum extractor is used during a vaginal birth.

2. The process in which the uterus returns to a non-pregnant state after birth is known as __________.

ANS: involution This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle.

1. The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering _____________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver.

ANS: thermogenesis Brown fat is located in superficial deposits in the interscapular region and axillae, as well as in deep deposits at the thoracic inlet, along the vertebral column and around the kidneys. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production by as much as 100%.

4. Nurses can prevent evaporative heat loss in the newborn by a. Drying the baby after birth and wrapping the baby in a dry blanket b. Keeping the baby out of drafts and away from air conditioners c. Placing the baby away from the outside wall and the windows d. Warming the stethoscope and nurse's hands before touching the baby

ANS: A Feedback A Because the infant is a wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. B Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. C If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiation heat loss. D Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.

32. What is the quickest and most common method to obtain neonatal blood for glucose screening 1 hour after birth? a. Puncture the lateral pad of the heel. b. Obtain a sample from the umbilical cord. c. Puncture a fingertip. d. Obtain a laboratory chemical determination.

ANS: A Feedback A A drop of blood obtained by heel stick is the quickest method of glucose screening. The calcaneus bone should be avoided as osteomyelitis may result from injury to the foot. B Most umbilical cords are clamped in the delivery room and are not available for routine testing. C A neonate's fingertips are too fragile to use for this purpose. D Laboratory chemical determination is the most accurate but the lengthiest method.

8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs

ANS: A Feedback A A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases fetal oxygen supply. B Maternal fatigue usually does not decrease uterine blood flow. C Maternal sedation will sedate the fetus but should not decrease blood flow. D Tocolytic drugs decrease contractions. This will increase uterine blood flow.

23. During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting go b. Taking hold c. Taking in d. Taking on

ANS: A Feedback A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. B During the taking-hold phase the mother assumes responsibility for her own care and shifts her attention to the infant. C In the taking-in phase the mother is primarily focused on her own needs. D There is no taking-on phase of maternal adjustment.

33. A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called a. Acrocyanosis b. Erythema neonatorum c. Harlequin color d. Vernix caseosa

ANS: A Feedback A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. B Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. C The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. D Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.

22. What is the priority nursing assessments for a woman receiving tocolytic therapy with terbutaline? a. Fetal heart rate, maternal pulse, and blood pressure b. Maternal temperature and odor of amniotic fluid c. Intake and output d. Maternal blood glucose

ANS: A Feedback A All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. B These are important if the membranes have ruptured, but they are not relevant to the medication. C This is not an important assessment to monitor for side effects of terbutaline. D This is not an important assessment to monitor for side effects of terbutaline.

27. In providing support to a new mother who must return to full-time employment 6 weeks after a vaginal delivery, the nurse should a. Allow her to express her positive and negative feelings freely. b. Reassure her that she'll get used to leaving her baby. c. Discuss child care arrangements with her. d. Allow her to solve the problem on her own.

ANS: A Feedback A Allowing the patient to express feelings will provide positive support in her process of maternal adjustment. B This blocks communication and belittles the patient's feelings. C This is an important step in anticipatory guidance, but is not the best way to offer support. D She should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision.

11. Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-, baby Rh+ b. Mother Rh-, baby Rh- c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh-

ANS: A Feedback A An Rh- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. B The blood types are alike, so no antibody formation would be anticipated. C The blood types are alike, so no antibody formation would be anticipated. D If the Rh+ blood of the mother comes in contact with the Rh- blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.

9. The nurse should alert the physician when a. The infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present at age 1 hour. c. The infant's blood glucose is 45 mg/dL. d. The infant goes into a deep sleep at age 1 hour.

ANS: A Feedback A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. B Acrocyanosis is an expected finding during the early neonatal life. C This is within normal range for a newborn. D Infants enter the period of deep sleep when they are about 1 hour old.

13. A woman in preterm labor at 30 weeks of gestation receives two 12 mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to a. Stimulate fetal surfactant production. b. Reduce maternal and fetal tachycardia associated with ritodrine administration. c. Suppress uterine contractions. d. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.

ANS: A Feedback A Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. B Inderal would be given to reduce the effects of ritodrine administration. C Betamethasone has no effect on uterine contractions. D Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.

4. Birth for the nulliparous woman with a fetus in a breech presentation is usually by a. Cesarean delivery b. Vaginal delivery c. Forceps-assisted delivery d. Vacuum extraction

ANS: A Feedback A Delivery for the nulliparous woman with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so that the infant can breathe. B The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so the infant can breathe. C The physician may assist rotation of the head with forceps. A cesarean birth may be required. D Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult.

17. The mother-baby nurse is able to recognize reciprocal attachment behavior. This refers to a. The positive feedback an infant exhibits toward parents during the attachment process b. Behavior during the sensitive period when the infant is in the quiet alert stage c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents

ANS: A Feedback A In this definition, reciprocal refers to the feedback from the infant during the attachment process. B This is a good time for bonding, but it does not define reciprocal attachment. C Reciprocal attachment is not unidirectional. D Reciprocal attachment deals with feedback behavior and is not unidirectional.

3. Which technique is least effective for the woman with persistent occiput posterior position? a. Lie supine and relax. b. Sit or kneel, leaning forward with support. c. Rock the pelvis back and forth while on hands and knees. d. Squat.

ANS: A Feedback A Lying supine increases the discomfort of "back labor." B A sitting or kneeling position may help the fetal head to rotate to occiput anterior. C Rocking the pelvis encourages rotation from occiput posterior to occiput anterior. D Squatting aids both rotation and fetal descent.

28. Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Place a blanket over the scale before weighing the infant. b. Maintain room temperature at 70° F. c. Undress the infant completely for assessments so they can be finished quickly. d. Take the rectal temperature every hour to detect early changes.

ANS: A Feedback A Padding the scale prevents heat loss from the infant to a cold surface by conduction. B Room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. C Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature due to convection. D Hourly assessments are not necessary for a normal newborn with a stable temperature.

11. Nurses can help parents deal with the issue and fact of circumcision if they explain a. The pros and cons of the procedure during the prenatal period b. That the American Academy of Pediatrics (AAP) recommends that all newborn males be routinely circumcised c. That circumcision is rarely painful and that any discomfort can be managed without medication d. That the infant will likely be alert and hungry shortly after the procedure

ANS: A Feedback A Parents need to make an informed choice regarding newborn circumcision based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. B The AAP and other professional organizations note the benefits, but stop short of recommendation for routine circumcision. C Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. D Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures.

7. In fetal circulation, the pressure is greatest in the a. Right atrium b. Left atrium c. Hepatic system d. Pulmonary veins

ANS: A Feedback A Pressure in fetal circulation is greatest in the right atrium, which allows a right-to-left shunting that aids in bypassing the lungs during intrauterine life. B The pressure increases in the left atrium after birth and will close the foramen ovale. C The liver does not filter the blood during fetal life until the end. It is functioning by birth. D Blood bypasses the pulmonary vein during fetal life.

22. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp

ANS: A Feedback A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. B The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. C The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. D Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes are touched, the infant's toes curl over the nurse's finger.

2. Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A Feedback A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. B Afterpains are particularly severe during breastfeeding, not bottle-feeding. C The uterus of a primipara tends to remain contracted. D The nonnursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse.

4. Which finding 12 hours after birth requires further assessment? a. The fundus is palpable two fingerbreadths above the umbilicus. b. The fundus is palpable at the level of the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: A Feedback A The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. B This is an appropriate assessment finding for 12 hours postpartum. C This is an appropriate assessment finding for 12 hours postpartum. D This is an unusual finding for 12 hours postpartum, but still appropriate.

15. Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a. Ideally the visit is scheduled between 24 and 72 hours after discharge. b. Home visits are available in all areas. c. Visits are completed within a 30-minute time frame. d. Blood draws are not a part of the home visit.

ANS: A Feedback A The home visit is ideally scheduled during the first 24 to 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. B Because home visits are expensive, they are not available in all geographic areas. C Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. D When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.

35. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."

ANS: A Feedback A This is an accurate statement and the most appropriate response. B Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. C This statement is not accurate. D This statement is not appropriate. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.

38. The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called a. Vernix caseosa b. Surfactant c. Caput succedaneum d. Acrocyanosis

ANS: A Feedback A This protection is needed because the infant's skin is so thin. B Surfactant is a protein that lines the alveoli of the infant's lungs. C Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. D Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

What risk factor for peripartum depression (PPD) is likely to have the greatest effect on the woman's condition? a. Personal history of depression b. Single-mother status c. Low socioeconomic status d. Unplanned or unwanted pregnancy

ANS: A A personal history of depression is a known risk factor for peripartum depression. Being single, from a low socioeconomic status, or having an unplanned or unwanted pregnancy may contribute to depression for some women but are not strong predictors.

Which measure may prevent mastitis in the breastfeeding mother? a. Initiating early and frequent feedings b. Nursing the infant for 5 minutes on each breast c. Wearing a tight-fitting bra d. Applying ice packs before feeding

ANS: A Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. Five minutes does not adequately empty the breast. This will produce stasis of the milk. A firm-fitting bra will support the breast but not prevent mastitis. The breast should not be bound. Warm packs before feeding will increase the flow of milk.

29. A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding? a. "I should encourage my baby to consume the entire amount of formula prepared for each feeding." b. "I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby." c. "I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby." d. "I will generally feed my baby every 3 to 4 hours or more as signs of hunger are displayed."

ANS: A Infants will stop suckling when they are full. Encouraging them to overeat may lead to problems with regurgitation and possible aspiration. The mother can prepare a single bottle or a 24-hour supply if adequate refrigeration is available. Show the parents how to position the infant in a semiupright position, such as the cradle hold. This allows them to hold the infant close in a face-to-face position. The bottle is held with the nipple kept full of formula to prevent excessive swallowing of air. Placing the infant in the opposite arm for each feeding provides varied visual stimulation during feedings. Feed the infant every 3 to 4 hours but avoid rigid scheduling and take cues from the infant. PTS: 1 DIF: Cognitive Level: Analysis REF: 458 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

1. The breastfeeding client should be taught a safe method to remove her breast from the baby's mouth. Which suggestion by the nurse is most appropriate? a. Break the suction by inserting your finger into the corner of the infant's mouth. b. A popping sound occurs when the breast is correctly removed from the infant's mouth. c. Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed. d. Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the baby cries.

ANS: A Inserting a finger into the corner of the baby's mouth between the gums to break the suction avoids trauma to the breast. A popping sound indicates improper removal of the breast from the baby's mouth and may cause cracks or fissures in the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple, making it sore. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended. PTS: 1 DIF: Cognitive Level: Application REF: 446 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse should expect medical intervention for subinvolution to include a. oral methylergonovine maleate (Methergine) for 48 hours. b. oxytocin intravenous infusion for 8 hours. c. oral fluids to 3000 mL/day. d. intravenous fluid and blood replacement.

ANS: A Methergine provides long-sustained contraction of the uterus and is the usual treatment. Oxytocin and oral fluids are not used for this condition. There is no indication that blood loss has occurred in this situation; if it does blood replacement may be necessary.

10. Which is an important consideration in positioning a newborn for breastfeeding? a. Placing the infant at nipple level facing the breast b. Keeping the infant's head slightly lower than the body c. Using the forefinger and middle finger to support the breast d. Limiting the amount of areola the infant takes into the mouth

ANS: A Positioning the infant at nipple level will prevent downward pulling of the nipple and subsequent nipple trauma. Keeping the infant's head slightly lower will pull the nipple down and cause trauma. The forefinger and middle finger can be used to support the breast, but this is not an important consideration in positioning the newborn. The infant should take in as much areola as possible to prevent trauma to the nipples. PTS: 1 DIF: Cognitive Level: Analysis REF: 444 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

11. The client should be taught that when her infant falls asleep after feeding for only a few minutes, she should do which of the following? a. Unwrap and gently arouse the infant. b. Wait an hour and attempt to feed again. c. Try offering a bottle at the next feeding. d. Put the infant in the crib and try again later.

ANS: A The infant who falls asleep during feeding may not have fed adequately and should be gently aroused to continue the feeding. Breastfeeding should continue. By offering a bottle, breast milk production will decrease. The infant should be aroused and feeding continued. PTS: 1 DIF: Cognitive Level: Application REF: 449 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by a. subinvolution of the uterus. b. defective vascularity of the decidua. c. cervical lacerations. d. coagulation disorders.

ANS: A The most common causes of late postpartum hemorrhage are subinvolution and retained placental fragments.

Early postpartum hemorrhage is defined as signs and symptoms of hypovolemia with which of the following descriptions of blood loss? a. Cumulative blood loss >1000 mL in the first 24 hours after the birth process. b. 750 mL in the first 24 hours after vaginal delivery c. Cumulative blood loss >1000 mL in the first 48 hours after the birth process d. 1500 mL in the first 48 hours after cesarean delivery

ANS: A The newest definition of early postpoartum hemorrhage is cumulative blood loss >1000 mL with signs of hypovolemia within the first 24 hours after the birth process. Hemorrhage after 24 hours is considered late postpartum hemorrhage.

9. Which is the first step in assisting the breastfeeding mother? a. Assess the woman's knowledge of breastfeeding. b. Provide instruction on the composition of breast milk. c. Discuss the hormonal changes that trigger the milk ejection reflex. d. Help her obtain a comfortable position and place the infant to the breast.

ANS: A The nurse should first assess the woman's knowledge and skill in breastfeeding to determine her teaching needs. Assessment should occur before instruction. Discussing the hormonal changes and helping her obtain a comfortable position may be part of the instructional plan, but assessment should occur first to determine what instruction is needed. PTS: 1 DIF: Cognitive Level: Application REF: 443, 444 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

A home health care nurse is checking on a new mother with signs of obsessive-compulsive disorder. What assessment findings correlate with this condition? (Select all that apply.) a. Frequently checking on the baby b. Fear of being alone with the baby c. Woman states she feels worthless d. Woman has bought $5,000 worth of toys e. Mother states birth was very traumatic

ANS: A, B Postpartum OCD often manifests with women performing obsessive behaviors and voicing fear of being left alone with their baby. Feeling worthless is a sign of depression. A spending spree might be a sign of the manic phase of bipolar disease. Viewing the birth as traumatic may lead to PTSD.

27. A mother conveys concern over the fact that she is not sure if her newborn child is getting enough nutrients from breastfeeding. This is the baby's first clinic visit after birth. What information can you provide that will help alleviate her fears about nutrient status for her newborn? a. Monitor the infant's output; as long as at least six or more diapers are changed in a 24-hour period, that should be sufficient. b. Tell the mother that if a baby is satisfied with feeding, she or he will be content and not fussy. c. Tell the mother that breast milk contains everything required for the infant and not to worry about nutrition. d. Provide nutrition information in the form of pamphlets for the mother to take home with her so that she uses them as a point of reference.

ANS: A The presence of wet diapers confirms that the infant is receiving enough milk. Recording weight and seeing an increase in weight is also an objective finding that can be used to note nutritional status. Newborns may be fussy and still be receiving adequate nutrition. Although breast milk is potentially the perfect food for the newborn, not everyone's breast milk has nutrient quality, so recording of weight gain and output measurements (wet diapers and stool production) confirm nutritional status. Providing the mother with educational pamphlets may be advisable but does not address the immediate problem. PTS: 1 DIF: Cognitive Level: Application REF: 448 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

24. A newborn infant weighs 7 pounds, 2 ounces, on the fifth day of life. How much water should be given to the newborn based on required fluid needs? a. Fluid replacement should be based on weight and calculated in the range of 60 to 100 mL/kg. b. Offer additional water to tolerance in between infant feedings to maintain hydration. c. Give 12 ounces of fluid per feeding. d. No water is needed because formula and breast milk are adequate to maintain hydration.

ANS: A There is an expected weight loss of up to 10% postdelivery, so fluid replacement should be calculated to improve health outcomes and maintain adequate hydration.12 ounces of fluid per feeding is excessive and may cause overdistention. Offering water between feedings to tolerance may not provide enough fluid replacement. Newborn infants require additional water to supplement feedings and support hydration. PTS: 1 DIF: Cognitive Level: Analysis REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is a. uterine atony. b. uterine inversion. c. vaginal hematoma. d. vaginal laceration.

ANS: A Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. The other situations can cause bleeding but are not the most common cause.

2. Which woman is most likely to continue breastfeeding beyond 6 months? a. A woman who avoids using bottles b. A woman who uses formula for every other feeding c. A woman who offers water or formula after breastfeeding d. A woman whose infant is satisfied for 4 hours after the feeding

ANS: A Women who avoid using bottles and formula are more likely to continue breastfeeding. Use of formula decreases breastfeeding time and decreases the production of prolactin and, ultimately, the milk supply. Overfeeding after breastfeeding causes a sense of fullness in the infant, so the infant will not be hungry in 2 to 3 hours. Formula takes longer to digest. The new breastfeeding mother needs to nurse often to stimulate milk production. PTS: 1 DIF: Cognitive Level: Analysis REF: 453 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

1. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cures indicating pain, measures should be taken to manage the infant's pain. Examples of nonpharmacologic pain management techniques include (select all that apply) a. Swaddling b. Nonnutritive sucking (pacifier) c. Skin-to-skin contact with the mother d. Sucrose e. Acetaminophen

ANS: A, B, C, D Feedback Correct These interventions are all appropriate nonpharmacologic techniques used to manage pain in neonates. Other interventions include soothing music, dim lighting and speaking to the infant in a quiet voice. Incorrect Acetaminophen is a pharmacologic method of treating pain.

What actions can the labor and delivery nurse take to decrease a woman's chance of contracting a puerperal infection? (Select all that apply.) a. Avoid straight catheterizing the woman unless she cannot void. b. Keep vaginal examinations to a minimum. c. Change wet peripads and linens frequently. d. Maintain the woman on bedrest while laboring. e. Use good hand hygiene before and after contact with the woman.

ANS: A, B, C, E Risk for infection increases with catheterization, vaginal examinations, exposure to wet linens and pads, and poor hand hygiene. Remaining on bedrest does not reduce the chance for infection.

Medications used to manage postpartum hemorrhage include which of the following? (Select all that apply.) a. Oxytocin b. Methergine c. Terbutaline d. Hemabate e. Magnesium sulfate

ANS: A, B, D Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.

The nurse explain to the student that which of the following factors increase a woman's risk for thrombosis? (Select all that apply.) a. Use of stirrups for a prolonged period of time b. Prolonged bedrest during or after labor and delivery c. Adherence to a strict vegetarian diet d. Excessive sweating during labor e. Maternal age greater than 30 years of age

ANS: A, B, D, E Use of stirrups for a prolonged period of time, bedrest, excessive sweating (leading to dehydration) all increase the risk of thrombosis. Vegetarian diets are not related. Maternal age >35 increases the risk.

2. As recently as 2005, the American Academy of Pediatrics revised safe sleep practices to assist in the prevention of sudden infant death syndrome. The nurse should model these practices in hospital and incorporate this information into the teaching for new parents. They include (select all that apply) a. Fully supine position for all sleep b. Side-sleeping position as an acceptable alternative c. "Tummy time" for play d. Placing the infant's crib in the parents' room e. A soft mattress

ANS: A, C, D Feedback Correct The back to sleep position is now recommended as the only position for every sleep period. To prevent positional plagiocephaly (flattening of the head) the infant should spend time on his or her abdomen while awake and for play. Loose sheets and blankets may be dangerous because they could easily cover the baby's head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. Ideally the infant's crib should be placed in the parents' room. Incorrect The side-sleeping position is no longer an acceptable alternative according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts, sheepskins, etc., should not be placed under the infant.

3. Hearing loss occurs in 9% of newborns. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (select all that apply) a. To prevent or reduce developmental delay b. Reassurance for concerned new parents c. Early identification and treatment d. To help the child communicate better e. To achieve one of the Healthy People 2020 goals

ANS: A, C, D, E Feedback Correct These are all appropriate reasons for auditory screening of the newborn. Infants who do not pass should be rescreened. If they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age. Incorrect New parents are often anxious regarding this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge. It is important for the nurse to ensure that the infant receives the appropriate testing and that the test is fully explained to the parents. For infants that are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support.

2. Many women given up smoking during pregnancy to protect the health of the fetus. The majority of women resumed smoking within the first 6 months postpartum. Factors that increase the likelihood of relapse include (select all that apply) a. Living with a smoker b. Returning to work c. Weight concerns d. Successful breastfeeding e. Failure to breastfeed

ANS: A, C, E Feedback Correct Other factors include intending to quit for pregnancy only, depression, and stress. Incorrect Successful breastfeeding is likely to inhibit smoking. Returning to work, although stressful, does not necessarily increase a return to smoking.

32. Late in pregnancy, the client's breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Which of the following nipple conditions make it necessary to intervene before birth. (Select all that apply.) a. Flat nipples b. Cracked nipples c. Everted nipples d. Inverted nipples e. Nipples that contract when compressed

ANS: A, D, E Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infant's mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra, with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells has been debated. A breast pump can be used to draw the nipples out before feedings after birth. Everted nipples protrude and are normal. No intervention will be required. Cracked, blistered, and bleeding nipples occur after breastfeeding has been initiated and are the result of improper latching on. The infant should be repositioned during feeding. The application of colostrum and breast milk after feedings will aid in healing. PTS: 1 DIF: Cognitive Level: Application REF: 451 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

23. Infants in whom cephalhematomas develop are at increased risk for a. Infection b. Jaundice c. Caput succedaneum d. Erythema toxicum

ANS: B Feedback A Cephalhematomas do not increase the risk for infections. B Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. C Caput is an edematous area on the head from pressure against the cervix. D Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.

20. An important independent nursing action to promote normal progress in labor is a. Assessing the fetus b. Encouraging urination about every 1 to 2 hours c. Limiting contact with the woman's partner d. Regulating intravenous fluids

ANS: B Feedback A Assessment of the fetus is an important task, but will not promote normal progression of labor. B The bladder can reduce room in the woman's pelvis that is needed for fetal descent and can increase her discomfort. C The woman needs her support system during labor, and contact should not be limited. D Maintaining hydration is an important task, but it will not promote normal progression of labor.

36. By knowing about variations in infants' blood count, nurses can explain to their patients that a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. The early high white blood cell count (WBC) is normal at birth and should decrease rapidly. c. Platelet counts are higher than in adults for a few months. d. Even a modest vitamin K deficiency means a problem with the blood's ability to clot properly.

ANS: B Feedback A Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count. B The WBC is high the first day of birth and then declines rapidly. C The platelet count essentially is the same for newborns and adults. D Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.

34. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and can distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."

ANS: B Feedback A Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. B This is an accurate statement. C Infants prefer to look at complex patterns, regardless of the color. D Infants prefer low illumination and withdraw from bright light.

11. Why is adequate hydration important when uterine activity occurs before pregnancy is at term? a. Fluid and electrolyte imbalance can interfere with the activity of the uterine pacemakers. b. Dehydration may contribute to uterine irritability for some women. c. Dehydration decreases circulating blood volume, which leads to uterine ischemia. d. Fluid needs are increased because of increased metabolic activity occurring during contractions.

ANS: B Feedback A Fluid and electrolyte imbalances are not associated with preterm labor. B Intravenous fluids are ordered according to their expected benefit. Adequate hydration promotes urination and decreased risk for infection. C The woman has an increase blood volume during pregnancy. D Fluid needs do not increase due to contractions.

25. Plantar creases should be evaluated within a few hours of birth because a. The newborn has to be footprinted. b. As the skin dries, the creases will become more prominent. c. Heel sticks may be required. d. Creases will be less prominent after 24 hours.

ANS: B Feedback A Footprinting will not interfere with the creases. B As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. C Heel sticks will not interfere with the creases. D The creases will appear more prominent after 24 hours.

16. To assess fundal contraction 6 hours after cesarean delivery, the nurse should a. Palpate forcefully through the abdominal dressing. b. Gently palpate, applying the same technique used for vaginal deliveries. c. Place hands on both sides of the abdomen and press downward. d. Rely on assessment of lochial flow rather than palpating the fundus.

ANS: B Feedback A Forceful palpation should never be used. B Assessment of the fundus is the same for both vaginal and cesarean deliveries; however, palpation should be gentle due to increased discomfort caused by the uterine incision. C The top of the fundus, not the sides, should be palpated and massaged. D The fundus should be palpated and massaged to prevent bleeding.

7. To prevent the kidnapping of newborns from the hospital, the nurse should a. Instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. b. Question anyone who is seen walking in the hallways carrying an infant. c. Allow no visitors in the maternity area except those who have identification bracelets. d. Restrict the amount of time infants are out of the nursery.

ANS: B Feedback A It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit. B Infants should be transported in the hallways only in their cribs. C This will be difficult to monitor and will limit the mother's support system from visiting. D Infants need to spend time with the parents to facilitate the bonding process.

24. Rupture of the amniotic sac before the onset of true labor, regardless of length of gestation is called premature rupture of membranes (PROM). The first priority for the nurse is to determine whether membranes are truly ruptured. Other explanations for this increase in fluid discharge include all except a. Urinary incontinence b. Leaking of amniotic fluid c. Loss of mucous plug d. An increase in vaginal discharge

ANS: B Feedback A It is not uncommon for patients to mistake urinary incontinence for leakage of amniotic fluid. B Leaking of amniotic fluid is an indication of PROM. C Loss of the mucous plug can lead a woman to believe that her membranes have ruptured when they have not. D Late in pregnancy there may be an increase in vaginal discharge. This may be mistaken for rupture of membranes.

2. When teaching parents about their newborn's transition to extrauterine life, the nurse explains which organs are nonfunctional during fetal life. They are the a. Kidneys and adrenals b. Lungs and liver c. Eyes and ears d. Gastrointestinal system

ANS: B Feedback A Kidneys and adrenals function during fetal life. The fetus continuously swallows amniotic fluid, which is filtered through the kidneys. B Most of the fetal blood flow bypasses the nonfunctional lungs and liver. C Near term, the eyes are open and the fetus can hear. D The gastrointestinal system functions during fetal life.

13. An unfortunate but essential role of the nurse is protecting the infant from abduction. Which statement regarding the profile of a potential abductor is the most accurate? a. Male gender b. A young woman who has had a previous pregnancy loss c. A middle-aged woman past childbearing age d. A female with a number of children of her own

ANS: B Feedback A Newborns are usually abducted by women who are familiar with the birth facility and its routines. B The woman is usually of childbearing age and may have had a previous pregnancy loss or has been unable to have a child of her own. She may want an infant to solidify the relationship with her husband or boyfriend and may have pretended to be pregnant. C Infant abductors are women of childbearing age, often overweight, who may live near the birth facility. D A woman who already has children of her own does not fit the profile of a potential abductor.

5. The nurse's initial action when caring for an infant with a slightly decreased temperature is to a. Notify the physician immediately. b. Place a cap on the infant's head and have the mother perform kangaroo care. c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. Change the formula, as this is a sign of formula intolerance.

ANS: B Feedback A Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. B A cap will prevent further heat loss from the head, and having the mother place the infant skin-to-skin should increase the infant's temperature. C A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. D Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.

9. If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the patient has a. Been lying on her right side too long b. A distended bladder c. Stretched ligaments that are unable to support the uterus d. A normal involution

ANS: B Feedback A Position of the patient should not alter uterine position. B The presence of a full bladder will displace the uterus. C The problem is a full bladder displacing the uterus. D This is not an expected finding.

21. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Ortolani's sign b. Thigh and gluteal creases are asymmetric c. Negative Barlow test d. Knee heights are equal

ANS: B Feedback A Positive Ortolani's sign yields a "clunking" sensation and indicates a dislocated femoral head moving into the acetabulum. B Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. C During a positive Barlow test, the examiner can feel the femoral head move out of acetabulum. D If the hip is dislocated, the knee on the affected side will be lower.

2. A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to a. Destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. c. Prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. Prevent the infant's eyelids from sticking together and help the infant see.

ANS: B Feedback A Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection. B This is an accurate explanation. C Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. It is instilled to prevent gonorrheal or chlamydial infection. D Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

14. When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is a. Rectal suppositories b. Early and frequent ambulation c. Tightening and relaxing abdominal muscles d. Carbonated beverages

ANS: B Feedback A Rectal suppositories can be helpful after distention occurs, but do not prevent it. B Activity can aid the movement of accumulated gas in the gastrointestinal tract. C Ambulation is the best prevention. D Carbonated beverages may increase distention.

2. A woman in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will probably be prescribed for at-home continuation of the tocolytic effect? a. Ritodrine b. Terbutaline c. Calcium gluconate d. Magnesium sulfate

ANS: B Feedback A Ritodrine is the only drug approved by the FDA for tocolysis; however, it is rarely used because of significant side effects. B The woman receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis. C Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. D Magnesium sulfate is usually given intravenously or intramuscularly. The patient must be hospitalized for magnesium therapy because of the serious side effects of this drug.

19. During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a. Anticipatory b. Formal c. Informal d. Personal

ANS: B Feedback A The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes. B A major task of the formal stage of role attainment is getting acquainted with the infant. C The informal stage begins once the parents have learned appropriate responses to their infant's cues. D The personal stage is attained when parents feel a sense of harmony in their role.

26. To promote bonding and attachment immediately after delivery, the nurse should a. Allow the mother quiet time with her infant. b. Assist the mother in assuming an en face position with her newborn. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in feeding her baby.

ANS: B Feedback A The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time. B Assisting the mother in assuming an en face position with her newborn will support the bonding process. C The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time. D This is a good time to initiate breastfeeding, but first the mother needs time to explore the new infant and begin the bonding process.

8. Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of a. Increased pressure in the right atrium b. Increased pressure in the left atrium c. Decreased blood flow to the left ventricle d. Changes in the hepatic blood flow

ANS: B Feedback A The pressure in the right atrium decreases at birth. It is higher during fetal life. B With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. C Blood flow increases to the left ventricle after birth. D The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale.

3. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the a. Transition period b. First period of reactivity c. Organizational stage d. Second period of reactivity

ANS: B Feedback A The transition period is the phase between intrauterine and extrauterine existence. B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. C There is no such phase as the organizational stage. D The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

25. A man calls the nurse's station stating that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, "She was never like this before the baby was born." The nurse's initial response should be to a. Tell him to ignore the mood swings, as they will go away. b. Reassure him that this behavior is normal. c. Advise him to get immediate psychological help for her. d. Instruct him in the signs, symptoms, and duration of postpartum blues.

ANS: B Feedback A This blocks communication and may belittle the husband's concerns. B Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. C Postpartum blues are a normal process that is short lived; no medical intervention is needed. D Client teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching.

27. A new mother asks, "Why are you doing a gestational age assessment on my baby?" The nurse's best response is a. "This must be done to meet insurance requirements." b. "It helps us identify infants who are at risk for any problems." c. "The gestational age determines how long the infant will be hospitalized." d. "It was ordered by your doctor."

ANS: B Feedback A This is not accurate information. B The nurse should provide the mother with accurate information about various procedures performed on the newborn. C Gestational age does not dictate hospital stays. Problems that occur due to gestational age may prolong the stay. D Assessing gestational age is a nursing assessment and does not have to be ordered.

16. The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as a. Enterohepatic circuit b. Conjugation of bilirubin c. Unconjugation of bilirubin d. Albumin binding

ANS: B Feedback A This is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and then is recycled into the intestine. B Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. C Unconjugated bilirubin is fat soluble. D Albumin binding is to attach something to a protein molecule.

18. The postpartum woman who continually repeats the story of her labor, delivery, and recovery experiences is a. Providing others with her knowledge of events b. Making the birth experience "real" c. Taking hold of the events leading to her labor and delivery d. Accepting her response to labor and delivery

ANS: B Feedback A This is to satisfy her needs, not others. B Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. C She is in the taking-in phase, trying to make the birth experience seem real. D She is trying to make the event real and is trying to separate the infant from herself.

A postpartum patient is at increased risk for postpartum hemorrhage if she delivers a(n) a. 5-lb, 2-oz infant with outlet forceps. b. 6.5-lb infant after a 2-hour labor. c. 7-lb infant after an 8-hour labor. d. 8-lb infant after a 12-hour labor.

ANS: B A rapid (precipitous) labor and delivery may cause exhaustion of the uterine muscle and prevent contraction. The use of forceps may cause lacerations that could lead to bleeding, but that is not as common as hemorrhage after a precipitous labor when they are used only in the outlet. Eight-hour and 12-hour labors are normal in length.

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. What action should the nurse take next? a. Continue to massage the fundus. b. Notify the provider. c. Recheck vital signs. d. Insert an indwelling urinary catheter.

ANS: B After taking these corrective actions, the nurse should contact the provider and anticipate collaborative care measures. Another nurse can assess vital signs. Since the woman just voided, an indwelling catheter is not needed.

If the nurse suspects a uterine infection in the postpartum patient, she should assess the a. pulse and blood pressure. b. odor of the lochia. c. episiotomy site. d. abdomen for distention.

ANS: B An abnormal odor of the lochia indicates infection in the uterus. The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and more specific. The infection may move to the episiotomy site if proper hygiene is not followed, but this does not demonstrate a uterine infection. The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section.

What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected.

ANS: B An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. Large clots after discharge are a sign of complications and should be reported.

23. A new mother asks whether she should feed her newborn colostrum because it is not real milk. The nurse's best answer includes which information? a. Colostrum is unnecessary for newborns. b. Colostrum is high in antibodies, protein, vitamins, and minerals. c. Colostrum is lower in calories than milk and should be supplemented by formula. d. Giving colostrum is important in helping the mother learn how to breast-feed before she goes home.

ANS: B Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Colostrum provides immunity and enzymes necessary to clean the gastrointestinal system, among other things. Supplementation is not necessary. It will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge, but the importance of the colostrum to the infant is top priority. PTS: 1 DIF: Cognitive Level: Application REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b. Assess the fundus for firmness. c. Take her blood pressure. d. Check the perineum for lacerations.

ANS: B Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. Calling for help is not needed unless corrective action does not improve the situation. Another nurse can take the blood pressure or the original nurse can do so after assessing the fundus and massaging it if needed. Checking the perineum for lacerations would be appropriate if the fundus was firm.

22. A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurse's best response? a. "Formula may turn sour after it is opened." b. "Bacteria can grow rapidly in warm milk." c. "Formula loses some nutritional value once it is opened." d. "This makes it easier to keep track of how much the baby is taking."

ANS: B Formula should not be saved from one feeding to the next because of the danger of rapid growth of bacteria in warm milk. Formula will have bacterial growth before turning sour. This will cause problems in a newborn with an immature immune system. The loss of some nutritional value after the formula is opened is not the reason for using fresh bottles with each feeding. The danger of bacterial growth is the main concern. PTS: 1 DIF: Cognitive Level: Application REF: 459 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

The nurse knows that a measure for preventing late postpartum hemorrhage is to a. administer broad-spectrum antibiotics. b. inspect the placenta after delivery. c. manually remove the placenta. d. pull on the umbilical cord to hasten the delivery of the placenta.

ANS: B If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. Manual removal of the placenta increases the risk of postpartum hemorrhage. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.

The patient who is being treated for endometritis is placed in Fowler's position because it a. promotes comfort and rest. b. facilitates drainage of lochia. c. prevents spread of infection to the urinary tract. d. decreases tension on the reproductive organs.

ANS: B Lochia and infectious material are eliminated by gravity drainage when the woman is placed in the Fowler's position.

Which woman is at greatest risk for early postpartum hemorrhage? a. A primiparous woman being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced c. A multiparous woman with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins

ANS: B Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. The other situations do not post risk factors or causes of early PPH.

A provider left an order for a woman to have Methylergonovine 0.2 mg IM. The nurse assesses the woman and finds her vital signs to be: temperature 37.9° C (100.2° F), pulse 90 beats/minute, respirations 18 breaths/minute, and blood pressure 152/90 mm Hg. What action by the nurse is most appropriate? a. Administer acetaminophen first. b. Check policy for administration. c. Give the medication as prescribed. d. Consult with the provider.

ANS: B Methylergonovine is contraindicated in women with hypertension. The nurse should check the agency's policy to see at what blood pressure reading this medication should be held. After checking the policy, the nurse can consult the provider if it can't be given. Acetaminophen is not related to this situation.

7. Which is the hormone necessary for milk production? a. Estrogen b. Prolactin c. Progesterone d. Lactogen

ANS: B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. PTS: 1 DIF: Cognitive Level: Understanding REF: 441 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

21. What is the most serious consequence of propping an infant's bottle? a. Colic b. Aspiration c. Dental caries d. Ear infections

ANS: B Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs. Colic can occur but is not the most serious consequence. Dental caries becomes a problem when milk stays on the gums for a long period of time. This may cause a buildup of bacteria that will alter the growing teeth buds. However, this is not the most serious consequence. Ear infections can occur when the warm formula runs into the ear and bacterial growth occurs. However, this is not the most serious consequence. PTS: 1 DIF: Cognitive Level: Understanding REF: 459 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

5. How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed infant need each day? a. 50 to 75 b. 100 to 110 c. 120 to 140 d. 150 to 200

ANS: B The term newborn being fed with formula requires 100 to 110 kcal/kg to meet nutritional needs each day. 50 to 75 kcal/kg is too little and 120 to 140 kcal/kg and 150 to 200 kcal/kg are too much. PTS: 1 DIF: Cognitive Level: Understanding REF: 436 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

26. A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, the nurse would designate a score of: a. 10 and document findings in the chart. b. 6 and further teach and assist the mother in feeding activities. c. 5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy. d. 8 and no further assistance is needed for feeding.

ANS: B The LATCH assessment tool is used to identify whether mothers need additional instruction in the area of breastfeeding. The LATCH categories are latch, audible communication/swallowing,type of nipple, comfort of breasts, and holding position of infant. The assessment data reveal a score of 6 (0 + 2 + 1 + 2 + 1) so the mother needs additional assistance during breastfeeding at this time. PTS: 1 DIF: Cognitive Level: Analysis REF: 443 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

25. A mother is breastfeeding her newborn infant but is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The best nursing response would be to: a. tell the client to wear a bra at all times to provide more support to breast tissue. b. have the client put the infant to her breast more frequently. c. place ice packs on breast tissue after infant feeding. d. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.

ANS: B The client may be experiencing signs of engorgement. Intervention methods such as placing the infant to feed more frequently may help prevent physical complaints of tenderness to milk accumulation. Wearing a bra at all times will not help resolve engorgement issues but can provide comfort. Ice packs provide symptomatic relief but do not resolve engorgement issues. Warm water compresses are more likely to provide comfort. Engorgement is not a normal finding but is a common presentation in nursing mothers. These symptoms will not dissipate with continuation of breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 442, 451 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests a. uterine atony. b. lacerations of the genital tract. c. perineal hematoma. d. infection of the uterus.

ANS: B Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm with uterine atony. A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be. With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise.

1. The causes of preterm labor are not fully understood although many factors have been associated with early labor. These include (select all that apply) a. Singleton pregnancy b. History of cone biopsy c. Smoking d. Short cervical length e. Higher level of education

ANS: B, C, D Feedback Correct A history of cone biopsy, smoking, and short cervical length are maternal risk factors for preterm labor. Others include chronic illness, DES exposure as a fetus, uterine abnormalities, obesity, previous preterm labor or birth, number of embryos implanted, preeclampsia, anemia, or infection. Incorrect Uterine distention caused by multifetal pregnancy or hydramnios are risk factors for preterm labor. Low educational level, low socioeconomic status, little or no prenatal care, poor nutrition, or non-white ethnicity are all demographic risk factors for preterm labor and birth.

1. What are modes of heat loss in the newborn? (Choose all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination

ANS: B, C, D Feedback Correct Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Incorrect Perspiration and urination are not modes of heat loss in newborns.

33. Which interventions may relieve symptoms of colic in the infant? (Select all that apply.) a. Increased stimulation of infant to provide distraction b. Burping infant frequently during feedings c. Feeding infant placed in an upright position d. Providing chamomile tea to infant e. Feeding infant on an on demand schedule

ANS: B, C, D The presence of colic is a self-limiting temporary condition seen in infants during the first few months of life. Although there are many theories about its cause, none has been determined to show direct causation. Providing a quiet environment and a consistent feeding schedule, positioning the infant in an upright position during feeding, burping the infant frequently, and using supplements or medications that have antispasmodic properties may be recommended. Chamomile tea is reported to have antispasmodic effects. Feeding the infant on an on demand schedule may exacerbate the condition as a result of overfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 458 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

1. Nurses must be aware of the conditions that increase the risk of hemorrhage, one of the most common complications of the puerperium. What are the conditions? Select all that apply. a. Primipara b. Rapid or prolonged labor c. Overdistention of the uterus d. Uterine fibroids e. Preeclampsia

ANS: B, C, D, E Feedback Correct Rapid or prolonged labor, overdistention of the uterus, uterine fibroids, and preeclampsia are all risk factors for postpartum hemorrhage. Incorrect Grand multiparity (5 or more pregnancies) is a risk factor for postpartum hemorrhage. Other risk factors include retained placenta, placenta previa, previous postpartum hemorrhage or placenta accreta, drugs (magnesium sulfate, tocolytics, oxytocin), and operative procedures.

35. A new mother asks the nurse, "How will I know early signs of hunger in my baby?" The nurse's best response is which of the following? (Select all that apply.) a. Crying b. Rooting c. Lip smacking d. Decrease in activity e. Sucking on the hands

ANS: B, C, E Early signs of hunger in a baby are rooting, lip smacking, and sucking on the hands. Crying is a late sign, and the baby's activity will increase, not decrease. PTS: 1 DIF: Cognitive Level: Application REF: 443 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

34. For which infant should the nurse anticipate the use of soy formula? (Select all that apply.) a. Preterm infant b. Infant with galactosemia c. Infant with phenylketonuria d. Infant with lactase deficiency e. Infant with a malabsorption disorder

ANS: B, D, E Soy formula may be given to infants with galactosemia or lactase deficiency or those whose families are vegetarians. Soy milk is derived from the protein of soybeans and supplemented with amino acids. The formulas are also used for infants with malabsorption disorders. The preterm infant may require a more concentrated formula, with more calories in less liquid. Modifications of other nutrients are also made. Human milk fortifiers can be added to breast milk to adapt it for preterm infants. Low-phenylalanine formulas are needed for infants with phenylketonuria, a deficiency in the enzyme to digest phenylalanine found in standard formulas. PTS: 1 DIF: Cognitive Level: Analysis REF: 438 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

A woman just received an injection of carboprost, 2500 mcg IM. What actions by the nurse take priority? (Select all that apply.) a. Assess for nausea and vomiting b. Assess fetal well-being. c. Administer acetaminophen for headache. d. Monitor urine output. e. Notify the provider immediately.

ANS: B, E The usual dose of carboprost is 250 mcg, so this excessive dose could lead to uterine rupture. The nurse monitors the woman for signs of this and continually monitors the fetus for well-being. The provider would be notified and agency policy followed for variance reporting. Nausea, vomiting, and headache are side effects of the usual dose of the drug. This drug is excreted through urine, so monitoring urine output is important but not as critical as checking fetal well-being and notifying the provider.

5. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous woman with ruptured membranes c. A multiparous woman at 39 weeks of gestation who is expecting twins d. A primigravida woman who has requested no analgesia during her labor

ANS: C Feedback A A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. B There is no indication that this woman's uterus is overdistended, which is the main cause of hypotonic dysfunction. C Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. D A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.

33. Two days ago, a woman gave birth to a full-term infant. Last night, she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is a. Elevated temperature caused by postpartum infection b. Increased basal metabolic rate after giving birth c. Loss of increased blood volume associated with pregnancy d. Increased venous pressure in the lower extremities

ANS: C Feedback A An elevated temperature causes chills and may cause dehydration, not diaphoresis and diuresis. B Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. C Within 12 hours of birth, women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. D Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities.

26. A newborn who is large for gestational age (LGA) is _____ percentile for weight. a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

ANS: C Feedback A An infant between the 10th and 90th percentiles is average for gestational age. B An infant in less than the 10th percentile is small for gestational age. C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. D This infant is considered average for gestational age.

14. When the nurse is in the process of health teaching it is very important that he or she consider the family's cultural beliefs regarding child care. One of these beliefs includes a. Arab women are anxious to breastfeed while still in the hospital. b. It is important to complement Asian parents about their new baby. c. Women from India tie a black thread around the infant's waist. d. In the Korean culture the patient's mother is the primary caregiver of the infant.

ANS: C Feedback A Arab women are hesitant to breastfeed in the birth facility and wish to wait until they are home and their milk comes in. B Asian parents may be uneasy when caregivers are too complementary about the baby or casually touch the infant's head. C Women from India may tie a black thread around the infant's wrist, ankle, or waist to ward off evil spirits. This thread should not be removed by the nurse. D In the Korean culture, the husband's mother is the primary caregiver for the infant and the mother during the early weeks.

21. A woman who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a. "Back pain is common at this time during pregnancy because you tend to stand with a sway back." b. "Acetaminophen is acceptable during pregnancy; however, you should not take aspirin." c. "You should come into the office and let the doctor check you." d. "Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication."

ANS: C Feedback A Back pain can also be a symptom of preterm labor and needs to be assessed. B The woman needs to be assessed for preterm labor before providing pain relief. C A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. D The woman needs to be assessed for preterm labor before providing pain relief.

1. A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurse's best response is a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when the nurse flexes your foot." d. "You have a 'fleshy' odor to your vaginal drainage."

ANS: C Feedback A Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. B Deep tendon reflexes should be 1+ to 2+. C Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis. D A "fleshy" odor, not a foul odor, is within normal limits.

32. Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Estrogen b. Progesterone c. Prolactin d. Human placental lactogen

ANS: C Feedback A Estrogen and progesterone levels decrease markedly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. B Estrogen and progesterone levels decrease markedly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. C Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. D Human placental lactogen levels dramatically decrease after expulsion of the placenta.

8. A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after delivery because of a. Increased estrogen b. Increased progesterone c. Decreased melanocyte-stimulating hormone d. Decreased human placental lactogen

ANS: C Feedback A Estrogen levels decrease after delivery. B Progesterone levels decrease after delivery. C Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after delivery. D Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation.

23. The nurse should suspect uterine rupture if a. Fetal tachycardia occurs. b. The woman becomes dyspneic. c. Contractions abruptly stop during labor. d. Labor progresses unusually quickly.

ANS: C Feedback A Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. B This is not an early sign of a rupture. C A large rupture of the uterus will disrupt its ability to contract. D Contractions will stop with a rupture.

29. What characteristic shows the greatest gestational maturity? a. Few rugae on the scrotum and testes high in the scrotum b. Infant's arms and legs extended c. Some peeling and cracking of the skin d. The arm can be positioned with the elbow beyond the midline of the chest

ANS: C Feedback A Few rugae on the scrotum show a younger age in the newborn. B Extended arms and legs is a sign of preterm infants. C Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. D This result of the scarf sign shows a younger newborn.

22. The best way for the nurse to promote and support the maternal-infant bonding process is to a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods.

ANS: C Feedback A Having the mother express her feelings is important, but it is not the best way to promote bonding. B The mother needs time to rest and recuperate; she should not be expected to do all of the care. C Close and frequent interaction between mother and infant, which is facilitated by rooming-in, is important in the bonding process. This is often referred to as the mother-baby care or couplet care. D The mother needs to observe the infant during all stages so she will be aware of what to expect when they go home.

18. What factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at station -3 d. Meconium-stained amniotic fluid

ANS: C Feedback A Hydramnios puts the woman at high risk for a prolapsed umbilical cord. B A very small fetus, normally preterm, puts the woman at risk for a prolapsed umbilical cord. C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. D Meconium-stained amniotic fluid shows that the fetus already has been compromised, but it does not increase the chance of a prolapsed cord.

19. In which infant behavioral state is bonding most likely to occur? a. Drowsy b. Active alert c. Quiet alert d. Crying

ANS: C Feedback A In the drowsy state the eyes may remain closed. If open they are unfocused. The infant is not interested in the environment at this time. B In the active alert state infants are often fussy, restless, and not focused. C In the quiet alert state, the infant is interested in his or her surroundings and will often gaze at the mother or father or both. D During the crying state the infant does not respond to stimulation and cannot focus on parents.

7. A woman is having her first child. She has been in labor for 15 hours. Two hours ago, her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago, her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description? a. Prolonged latent phase b. Protracted active phase c. Secondary arrest d. Protracted descent

ANS: C Feedback A In the nulliparous woman, a prolonged latent phase typically lasts more than 20 hours. B A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). C With a secondary arrest of the active phase, the progress of labor has stopped. This patient has not had any anticipated cervical change, indicating an arrest of labor. D With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor.

14. A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is a. Seen at age 3 days b. The residue of a milk curd c. Passed in the first 12 hours of life d. Lighter in color and looser in consistency

ANS: C Feedback A Meconium stool is the first stool of the newborn. B Meconium stool is made up of matter in the intestines during intrauterine life. C Meconium stool is usually passed in the first 12 hours of life and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, obstruction is suspected. D Meconium is dark in color and sticky.

24. A maculopapular rash with a red base and a small white papule in the center is a. Milia b. Mongolian spots c. Erythema toxicum d. Cafe-au-lait spots

ANS: C Feedback A Milia are minute epidermal cysts on the face of the newborn. B Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. C This is a description of erythema toxicum, a normal rash in the newborn. D These spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in newborns.

12. In planning for home care of a woman with preterm labor, the nurse needs to address which concern? a. Nursing assessments will be different from those done in the hospital setting. b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor. c. Prolonged bed rest may cause negative physiologic effects. d. Home health care providers will be necessary.

ANS: C Feedback A Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. B Restricted activity and medication may prevent preterm labor; however, not in all women. Additionally, the plan of care is individualized to meet the needs of each patient. C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery. D Many women will receive home health nurse visits, but care is individualized for each woman.

5. A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."

ANS: C Feedback A Pathologic jaundice occurs during the first 24 hours of life. B Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. D Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

9. As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is a. To protect the baby from infection b. It is part of the Apgar protocol c. To protect the nurse from contamination by the newborn d. Because the nurse has primary responsibility for the baby during the first 2 hours

ANS: C Feedback A Proper hand hygiene is all that is necessary to protect the infant from infection. B Wearing gloves is not necessary in order to complete the Apgar score assessment. C With the possibility of transmission of viruses such as HBV and HIV through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. D The nurse assigned to the mother-baby couplet has primary responsibility regardless of whether or not she wears gloves.

11. What is a result of hypothermia in the newborn? a. Shivering to generate heat b. Decreased oxygen demands c. Increased glucose demands d. Decreased metabolic rate

ANS: C Feedback A Shivering is not an effective method of heat production for newborns. B Oxygen demands increase with hypothermia. C In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. D The metabolic rate increases with hypothermia.

5. If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, the nurse should a. Tell the physician immediately. b. Have the laboratory draw blood for reanalysis. c. Recognize that this is an acceptable range at this point postpartum. d. Begin antibiotic therapy immediately.

ANS: C Feedback A Since this is a normal finding there is no reason to alert the physician. B There is no need for reassessment since it is expected for the WBCs to be elevated. C Marked leucocytosis occurs with WBC counts increasing to as high as 30,000/mm3during labor and the immediate postpartum period. The WBC falls to normal within 6 days postpartum. D Antibiotics are not needed because the elevated WBCs are due to stress of labor and not an infectious process.

10. With regard to lab tests and diagnostic tests in the hospital after birth, nurses should be aware that a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. Federal law prohibits newborn genetic testing without parental consent. c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. d. Hearing screening is now mandated by federal law.

ANS: C Feedback A States all test for PKU and hypothyroidism, but other genetic defects are not universally covered. B Federal law mandates newborn genetic screening; however, parents can decline testing. A waiver should be signed and a notation made in the infant's medical record. C If testing is done prior to 24 hours of age, genetic screening should be repeated when the infant is 1 to 2 weeks old. D Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the U.S. the majority (95%) of infants are screened for hearing loss prior to discharge from the hospital.

9. After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should a. Give supplemental oxygen with a small facemask. b. Encourage the parents to hold the infant. c. Palpate the infant's clavicles. d. Perform a complete newborn assessment.

ANS: C Feedback A The Apgar indicates that no respiratory interventions are needed. B The infant needs to be assessed for clavicle fractures before excessive movement. C Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. D A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant.

6. To provide competent newborn care, the nurse understands that respirations are initiated at birth as a result of a. An increase in the PO2 and a decrease in PCO2 b. The continued functioning of the foramen ovale c. Chemical, thermal, sensory, and mechanical factors d. Drying off the infant

ANS: C Feedback A The PO2 decreases at birth and the PCO2 increases. B The foramen ovale closes at birth. C A variety of these factors are responsible for initiation of respirations. D Tactile stimuli aid in initiating respirations, but are not the main cause.

1. A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital, 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base her reply? a. After circumcision, the diaper should be changed frequently and fastened snugly. b. This yellow crust is an early sign of infection. c. The yellow crust should not be removed. d. Discontinue the use of petroleum jelly to the tip of the penis.

ANS: C Feedback A The diaper should be fastened loosely to prevent rubbing or pressure on the incision site. B The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. C Crust is a normal part of healing. D The only contraindication for petroleum jelly is the use of a PlastiBell.

17. Which statement is correct regarding the fluid balance in a newborn versus that in an adult? a. The infant has a smaller percentage of surface area to body mass. b. The infant has a smaller percentage of water to body mass. c. The infant has a greater percentage of insensible water loss. d. The infant has a 50% more effective glomerular filtration rate.

ANS: C Feedback A The infant's surface area is large compared to an adult's. B Infants have a larger percentage of water to body mass. C Insensible water loss is greater in the infant due to the newborn's large body surface area and rapid respiratory rate. D The filtration rate is less than in adults; the kidneys are immature in a newborn.

15. What documentation on a woman's chart on postpartum day 14 indicates a normal involution process? a. Moderate bright red lochial flow b. Breasts firm and tender c. Fundus below the symphysis and not palpable d. Episiotomy slightly red and puffy

ANS: C Feedback A The lochia should be changed by this day to serosa. B Breasts are not part of the involution process. C The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. D The episiotomy should not be red or puffy at this stage.

3. The normal term infant has little difficulty clearing its airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can easily be cleared with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to a. Avoid suctioning the nares. b. Insert the compressed bulb into the center of the mouth. c. Suction the mouth first. d. Remove the bulb syringe from the crib when finished.

ANS: C Feedback A The nasal passages should be suctioned one nostril at a time. The mouth should always be suctioned first. B After compression of the bulb it should be inserted into one side of the mouth. If it is inserted into the center of the mouth, the gag reflex is likely to be initiated. C The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. D When the infant's cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The bulb syringe should remain in the crib so that it is easily accessible if needed again.

10. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is _____ beats/min. a. 80 to 100 b. 100 to 120 c. 120 to 160 d. 150 to 180

ANS: C Feedback A The newborn's heart rate may be about 85 to 100 beats/min while sleeping. B The infant's heart rate typically is a bit higher when alert but quiet. C The average infant heart rate while awake is 120 to 160 beats/min. D A heart rate of 150 to 180 beats/min is typical when the infant cries.

37. With regard to the newborn's developing cardiovascular system, nurses should be aware that a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) often is visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C Feedback A The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. B Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. C The newborn's thin chest wall often allows the PMI to be seen. D Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

6. Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture

ANS: C Feedback A There is no correlation between bladder distention and eclampsia. B There is no correlation between bladder distention and blood pressure or fevers. C Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. D The risk of uterine rupture decreases after the birth.

20. Heat loss by convection occurs when a newborn is a. Placed on a cold circumcision board b. Given a bath c. Placed in a drafty area of the room d. Wrapped in cool blankets

ANS: C Feedback A This is conduction. B This is evaporation. C Convection occurs when infants are exposed to cold air currents. D This is conduction.

20. On observing a woman on her first postpartum day sitting in bed while her newborn lies awake in the bassinet, the nurse should a. Realize that this situation is perfectly acceptable. b. Offer to hand the baby to the woman. c. Hand the baby to the woman. d. Explain "taking in" to the woman.

ANS: C Feedback A This is expected behavior during the taking-in phase. However, interventions can facilitate infant bonding. B The woman is dependent and passive at this stage and may have difficulty making a decision. C During the "taking-in" phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. D She learns best during the taking-hold phase.

13. In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is a. Important in the production of red blood cells b. Necessary in the production of platelets c. Not initially synthesized because of a sterile bowel at birth d. Responsible for the breakdown of bilirubin and prevention of jaundice

ANS: C Feedback A Vitamin K is important for blood clotting. B The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. D Vitamin K is necessary to activate the clotting factors.

8. The nurse administers vitamin K to the newborn for what reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant's being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

ANS: C Feedback A Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. B Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. C This is an accurate statement. D Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.

6. A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman's labor? a. She is exhibiting hypotonic uterine dysfunction. b. She is experiencing a normal latent stage. c. She is exhibiting hypertonic uterine dysfunction. d. She is experiencing pelvic dystocia.

ANS: C Feedback A With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor and then the contractions become weak and inefficient or stop altogether. B The contraction pattern seen in this woman signifies hypertonic uterine activity. C Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, often are anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. D Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.

Nursing measures that help prevent postpartum urinary tract infection include which of the following? a. Promoting bed rest for 12 hours after delivery b. Discouraging voiding until the sensation of a full bladder is present c. Forcing fluids to at least 3000 mL/day d. Encouraging the intake of orange, grapefruit, or apple juice

ANS: C Adequate fluid intake of 2500 to 3000 mL/day prevents urinary stasis, dilutes urine, and flushes out waste products. The woman should be encouraged to ambulate early. With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. The woman needs to be encouraged to void frequently. Juices such as cranberry juice can discourage bacterial growth.

31. The nurse is teaching a postpartum client different holds for breastfeeding. Which of the following figures depicts the football hold frequently used for clients who have had a cesarean birth? a. b. c. d.

ANS: C For the football or clutch hold, the mother supports the infant's head and neck in her hand, with the infant's body resting on pillows next to her hip. This method allows the mother to see the position of the infant's mouth on the breast, helps her control the infant's head, and is especially helpful for mothers with heavy breasts. This hold also avoids pressure against an abdominal incision. For the cradle hold, the mother positions the infant's head at or near the antecubital space and level with her nipple, with her arm supporting the infant's body. Her other hand is free to hold the breast. The cross-cradle or modified cradle hold is helpful for infants who are preterm or have a fractured clavicle. The mother holds the infant's head with the hand opposite the side on which the infant will feed and supports the infant's body across her lap with her arm. The other hand holds the breast. The side-lying position avoids pressure on the episiotomy or abdominal incision and allows the mother to rest while feeding. PTS: 1 DIF: Cognitive Level: Analysis REF: 445 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE

28. A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once her breast milk comes in. What is the nurse's best response? a. "Are you concerned about your ability to adequately nurse your baby?" b. "Do you eat a well-balanced diet, high in protein and carbohydrates?" c. "Breast milk is low in vitamin D and supplementation with 400 IU is recommended." d. "Your breast milk has all the vitamins and will adequately meet your baby's needs."

ANS: C Generally, nutrients provided in breast milk are present in amounts and proportions needed by the infant. However, recent studies have shown that the vitamin D content of breast milk is low, and daily supplementation with 400 IU of vitamin D is recommended within the first few days of life. Breastfeeding infants who are not exposed to the sun and those with dark skin are particularly at risk for insufficient vitamin D. Formula-fed infants who drink less than 1 quart of vitamin D-fortified milk per day should also be supplemented. Although the fatty acid content of breast milk is influenced by the mother's diet, malnourished mothers' milk has about the same proportions of total fat, protein, carbohydrates, and most minerals as milk from those who are well nourished. Levels of water-soluble vitamins in breast milk are affected by the mother's intake and stores. It is important for breastfeeding women to eat a well-balanced diet to maintain their own health and energy levels. PTS: 1 DIF: Cognitive Level: Application REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

3. In which condition is breastfeeding contraindicated? a. Triplet birth b. Flat or inverted nipples c. Human immunodeficiency virus infection d. Inactive, previously treated tuberculosis

ANS: C Human immunodeficiency virus is a serious illness that can be transmitted to the infant via body fluids. Because the amount of milk being produced depends on the amount of suckling of the breasts, providing enough milk should not be a problem. Nipple abnormality can begin to be treated during pregnancy but may begin after birth. Many methods help flat or inverted nipples to become more erect. Only active tuberculosis patients would be cautioned not to breastfeed. PTS: 1 DIF: Cognitive Level: Understanding REF: 454 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment

The maternity nurse knows that which disorder can be triggered by a birth the woman views as traumatic? a. A phobia b. Panic disorder c. Posttraumatic stress disorder (PTSD) d. Obsessive-compulsive disorder (OCD)

ANS: C In PTSD, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event. This will not lead to phobias, panic disorder, or OCD.

Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth? a. Roll a bath blanket and place it firmly behind the knees. b. Limit oral intake of fluids for the first 24 hours. c. Assist the patient in performing gentle leg exercises. d. Ambulate the patient as soon as her vital signs are stable.

ANS: C Leg exercises and passive range of motion promote venous blood flow and prevent venous stasis while the patient is still on bed rest. The blanket behind the knees will cause pressure and decrease venous blood flow. Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis. The patient may not have full return of leg movements, and ambulating is contraindicated until she has full motion and sensation.

8. Which recommendation should the nurse make to a client to initiate the milk ejection reflex? a. Wear a well-fitting firm bra. b. Drink plenty of fluids. c. Place the infant to the breast. d. Apply cool packs to the breast.

ANS: C Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. A firm bra is important to support the breast but will not initiate the let-down reflex. Drinking plenty of fluids is necessary for adequate milk production but will not initiate the let-down reflex. Cool packs to the breast will decrease the let-down reflex. PTS: 1 DIF: Cognitive Level: Application REF: 441 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

To provide adequate postpartum care, the nurse should be aware that peripartum depression (PPD) a. is the "baby blues," plus the woman has a visit with a counselor or psychologist. b. does not affect the father who can then care for the baby. c. is distinguished by pervasive sadness that lasts at least 2 weeks. d. will disappear on its own without outside help.

ANS: C PPD is characterized by a persistent depressed state. The woman is unable to feel pleasure or love although she is able to care for her infant. She often experiences generalized fatigue, irritability, little interest in food and sleep disorders. PPD is more serious and persistent than postpartum baby blues. Fathers are often affected. Most women need professional help to get through PPD, including pharmacologic intervention.

4. Which type of formula should not be diluted before being administered to an infant? a. Powdered b. Concentrated c. Ready to use d. Modified cow's milk

ANS: C Ready to use formula can be poured directly from the can into the baby's bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cow's milk is more difficult for the infant to digest and is not recommended, even if it is diluted. PTS: 1 DIF: Cognitive Level: Understanding REF: 458 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

The mother-baby nurse must be able to recognize what sign of thrombophlebitis? a. Visible varicose veins b. Positive Homans sign c. Local tenderness, heat, and swelling d. Pedal edema in the affected leg

ANS: C Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. Varicose veins may predispose the woman to thrombophlebitis but are not a sign. A positive Homans sign may be caused by a strained muscle or contusion. Edema may be caused by other factors, and the edema with thrombophlebitis may be more extensive. Edema may be more involved than pedal.

30. A client who is receiving a pitocin (Oxytocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority? a. Increase the rate of pitocin infusion to help spread out the contraction pattern. b. Place oxygen on the client at 8 to 10 L/min via face mask and turn the client to her left side. c. Stop the pitocin infusion. d. Call the physician to obtain an order for the initiation of magnesium sulfate.

ANS: C The client is exhibiting uterine tachysystole (uterine tetany). The priority intervention is to stop the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be contacted for additional orders. PTS: 1 DIF: Cognitive Level: Analysis REF: 441 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

15. A new mother is concerned because her 1-day-old newborn is taking only 1 oz at each feeding. What should the nurse explain? a. The infant is probably having difficulty adjusting to the formula. b. An infant does not require as much formula in the first few days of life. c. The infant's stomach capacity is small at birth but will expand within a few days. d. The infant tires easily during the first few days but will gradually take more formula.

ANS: C The infant's stomach capacity at birth is 10 to 20 mL and increases to 30 to 90 mL by the end of the first week. There are other symptoms if there is a formula intolerance. The infant's requirements are the same, but the stomach capacity needs to increase before taking in adequate amounts. The infant's sleep patterns do change, but the infant should be awake enough to feed. PTS: 1 DIF: Cognitive Level: Application REF: 446 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

6. How many milliliters per kilogram (mL/kg) of fluids does a newborn need daily for the first 3 to 5 days of life? a. 20 to 30 b. 40 to 60 c. 60 to 100 d. 120 to 150

ANS: C The newborn needs 60 to 100 mL/kg of fluids daily for the first 3 to 5 days of life. 20 to 30 mL/kg and 40 to 60 mL/kg are too small an amount for the newborn. 120 to 150 mL/kg is too large an amount for the newborn. PTS: 1 DIF: Cognitive Level: Understanding REF: 436, 437 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

14. How many ounces will an infant who is on a 4-hour feeding schedule need to consume at each feeding to meet daily caloric needs? a. 1 b. 1.5 c. 3.5 d. 5

ANS: C The newborn requires approximately 12 to 24 oz of formula each day (6 feedings/24-hour period). 1 and 1.5 ounces are too small to meet calorie needs; 5 ounces with every feeding would be overfeeding the infant. PTS: 1 DIF: Cognitive Level: Analysis REF: 459 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that a. the infant is protected from infection by immunoglobulins in the breast milk. b. the infant is not susceptible to the organisms that cause mastitis. c. the organisms that cause mastitis are not passed to the milk. d. the organisms will be inactivated by gastric acid.

ANS: C The organisms are localized in the breast tissue and are not excreted in the breast milk. The mother is just producing the immunoglobulin from this infection, so it is not available for the infant. Because of an immature immune system, infants are susceptible to many infections. However, this infection is in the breast tissue and is not excreted in the breast milk. The organism will not get into the infant's gastrointestinal system.

When a woman is diagnosed with postpartum psychosis, one of the main concerns is that she may a. have outbursts of anger. b. neglect her hygiene. c. harm her infant. d. lose interest in her husband.

ANS: C Thoughts of harm to one's self or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. The other problems can be attributed to postpartum psychosis, but the major concern is harm to the infant.

10. A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy.

ANS: D Feedback A A multiparous classification is not an indication for these orders. B A vacuum-assisted birth may be used in conjunction with an episiotomy, which indicates these interventions. C Use of epidural anesthesia has no correlation with these orders. D These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids.

17. Which action should be initiated to limit hypovolemic shock when uterine inversion occurs? a. Administer oxygen at 31 L/min by nasal cannula. b. Administer an oxytocic drug by intravenous push. c. Monitor fetal heart rate every 5 minutes. d. Restore circulating blood volume by increasing the intravenous infusion rate.

ANS: D Feedback A Administering oxygen will not prevent hypovolemic shock. B Oxytocin drugs should not be given until the uterus is repositioned. C A uterine inversion occurs during the third stage of labor. D Intravenous fluids are necessary to replace the lost blood volume that occurs in uterine inversion.

31. The nurse caring for the postpartum woman understands that breast engorgement is caused by a. Overproduction of colostrum b. Accumulation of milk in the lactiferous ducts and glands c. Hyperplasia of mammary tissue d. Congestion of veins and lymphatics

ANS: D Feedback A Breast engorgement is not the result of overproduction of colostrum. B Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. C Hyperplasia of mammary tissue does not cause breast engorgement. D Breast engorgement is caused by the temporary congestion of veins and lymphatics.

12. The infant with the lowest risk of developing high levels of bilirubin is the one who a. Was bruised during a difficult delivery b. Developed a cephalhematoma c. Uses brown fat to maintain temperature d. Breastfeeds during the first hour of life

ANS: D Feedback A Bruising will release more bilirubin into the system. B Cephalhematomas will release bilirubin into the system as the red blood cells die off. C Brown fat is normally used to produce heat in the newborn. D The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the intestines back into the circulation.

4. In providing and teaching cord care, what is an important principle? a. Cord care is done only to control bleeding. b. Alcohol is the only agent used for cord care. c. It takes a minimum of 24 days for the cord to separate. d. The process of keeping the cord dry will decrease bacterial growth.

ANS: D Feedback A Cord care is to prevent infection and add in the drying of the cord. B No agents are necessary to facilitate drying of the cord. C The cord will fall off within 10 to 14 days. D Bacterial growth increases in a moist environment, so keeping the umbilical cord dry impedes bacterial growth.

29. A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman a. "Didn't you like your lunch?" b. "Does your doctor know that you are planning to eat that?" c. "What is that anyway?" d. "I'll warm the soup in the microwave for you."

ANS: D Feedback A Cultural dietary preferences must be respected. B Women may request that family members bring favorite or culturally appropriated foods to the hospital. C Cultural dietary preferences must be respected. A statement such as this does not show cultural sensitivity. D This statement shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response.

35. Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the patient understands the correct process for completing these conditioning exercises when she reports a. "I contract my thighs, buttocks, and abdomen." b. "I do 10 of these exercises every day." c. "I stand while practicing this new exercise routine." d. "I pretend that I am trying to stop the flow of urine midstream."

ANS: D Feedback A Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. B Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. C The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees. D The woman can pretend that she is attempting to stop the passing of gas, or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward.

14. With regard to the care management of preterm labor, nurses should be aware that a. Because all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching pregnant women the symptoms probably causes more harm through false alarms. b. Braxton Hicks contractions often signal the onset of preterm labor. c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver. d. The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

ANS: D Feedback A It is essential that nurses teach women how to detect the early symptoms of preterm labor. B Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. C Waiting too long to see a health care provider could result in essential medications' failing to be administered. Preterm labor is not necessarily long-term labor. D Gestational age of 20 to 37 weeks, uterine contractions, and a thinning cervix are all indications of preterm labor.

28. A new father states, "I know nothing about babies," but he seems to be interested in learning. The nurse should a. Continue to observe his interaction with the newborn. b. Tell him when he does something wrong. c. Show no concern, as he will learn on his own. d. Include him in teaching sessions.

ANS: D Feedback A It is important to note the bonding process of the mother and the father, but that does not satisfy the expressed needs of the father. B He should be encouraged by pointing out the correct procedures he does. Criticizing him will discourage him. C This is not a nursing role. Nurses need to be sensitive to patients' needs. D The nurse must be sensitive to the father's needs and include him whenever possible. As fathers take on care new role, the nurse should praise every attempt even if his early care is awkward.

31. An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called a. Lanugo b. Vascular nevi c. Nevus flammeus d. Mongolian spots

ANS: D Feedback A Lanugo is the fine, downy hair seen on a term newborn. B A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. C A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face. D A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African.

13. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.

ANS: D Feedback A Nursing actions need to be implemented before notifying the physician. B This is an important assessment if the bleeding continues. However, the focus should be on controlling the bleeding. C The focus needs to be on controlling the bleeding. D Urinary retention can cause overdistention of the urinary bladder, which lifts and displaces the uterus.

30. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse might try is a. Pouring water from a squeeze bottle over the woman's perineum b. Providing hot tea c. Asking the physician to prescribe analgesics d. Inserting a sterile catheter

ANS: D Feedback A Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early on. B Hot tea or other fluids ad lib is an easy, noninvasive strategy, that should be tried early on. C If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means could be tried first, but medications still come before insertion of a catheter. D Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain pills).

16. A woman who had two previous cesarean births is in active labor, when she suddenly complains of pain between her scapulae. The nurse's priority action is to a. Reposition the woman with her hips slightly elevated. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Notify the physician promptly and prepare the woman for surgery.

ANS: D Feedback A Repositioning the woman with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties. B Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the woman at high risk for uterine rupture. C The woman is now at high risk for shock. Nonadditive intravenous fluids should be increased. D Pain between the scapulae may occur when the uterus ruptures, because blood accumulates under the diaphragm. This is an emergency that requires medical intervention.

7. A postpartum patient asks, "Will these stretch marks go away?" The nurse's best response is a. "They will continue to fade and should be gone by your 6-week checkup." b. "No, never." c. "Yes, eventually." d. "They will fade to silvery lines but won't disappear completely."

ANS: D Feedback A Stretch marks do not disappear. B This is true, but more information can be added, such as the changes that will occur with the stretch marks. C This is not a true statement; they will not disappear. D Stretch marks never disappear altogether, but they gradually fade to silvery lines.

3. Which maternal event is abnormal in the early postpartum period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D Feedback A The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. B Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. C The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor. D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white.

19. The fetus in a breech presentation is often born by cesarean delivery because a. The buttocks are much larger than the head. b. Postpartum hemorrhage is more likely if the woman delivers vaginally. c. Internal rotation cannot occur if the fetus is breech. d. Compression of the umbilical cord is more likely.

ANS: D Feedback A The head is the largest part of a fetus. B There is no relationship between breech presentation and postpartum hemorrhage. C Internal rotation can occur with a breech. D After the fetal legs and trunk emerge from the woman's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head.

15. When the newborn infant is fed, the most likely cause of regurgitation is a. Placing the infant in a prone position after a feeding b. The gastrocolic reflex c. An underdeveloped pyloric sphincter d. A relaxed cardiac sphincter

ANS: D Feedback A The infant should be placed in a supine position. B The gastrocolic reflex increases intestinal peristalsis after the stomach fills. C The pyloric sphincter goes from the stomach to the intestines. D The underlying cause of newborn regurgitation is a relaxed cardiac sphincter.

12. If rubella vaccine is indicated for a postpartum patient, instructions to the patient should include a. Drinking plenty of fluids to prevent fever b. No specific instructions c. Recommending that she stop breastfeeding for 24 hours after injection d. Explaining the risks of becoming pregnant within 1 month after injection

ANS: D Feedback A The mother should be afebrile before the vaccine. B The mother does need to understand potential side effects, and that pregnancy is discouraged for at least 28 days after receiving the vaccine. C Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding. D Potential risks to the fetus can occur if pregnancy results within 28 days after rubella vaccine administration.

21. A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should a. Report the incident to the social services department. b. Advise the parents that the toddler needs to be reprimanded. c. Report to oncoming staff that the mother is probably not a good disciplinarian. d. Realize that this is a normal family adjusting to family change.

ANS: D Feedback A There is no need to report this one incident. B Giving advice at this point would make the parents feel inadequate as parents. C This is normal for an adjusting family. D The observed behaviors are normal variations of families adjusting to change.

1. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

ANS: D Feedback A This is a common condition for infants delivered by cesarean section. B Surfactant is produced by the lungs, so aspiration is not a concern. C It is common to have some fluid left in the lungs; this will be absorbed within a few hours. D The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems.

24. A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to a. Assess her for pain. b. Point out how lucky she is to have a healthy baby. c. Explain that she is experiencing postpartum blues. d. Allow her time to express her feelings.

ANS: D Feedback A This is an assumption that she is in pain. B This is blocking communication. C She needs the opportunity to express her feelings first. Later, patient teaching can occur. D Although many women experience transient postpartum blues, they need assistance in expressing their feelings. This condition affects 70-80% of new mothers.

30. A sign of illness in the newborn is a. More than two soft stools per day b. Regurgitating a small amount of feeding c. A yellow scaly lesion on the scalp d. An axillary temperature greater than 37.5° C

ANS: D Feedback A This is an expected finding in the newborn. B This is an expected finding in the newborn. C This is a sign of cradle cap or seborrhea capitis. D Infants commonly respond to a variety of illnesses with an elevation in temperature. The normal range for an axillary temperature in the newborn is 36.5° to 37.3° C.

6. When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to a. Keep the state records updated. b. Allow accurate statistical information. c. Document the number of births. d. Recognize and treat newborn disorders early.

ANS: D Feedback A This is not the main reason for the screening test. B This is not the main reason for the screening test. C The number of births does not come from the newborn screening test. D Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions.

18. The most likely interpretation of an elevated immunoglobulin M (IgM) level in a newborn is a. The infant was breastfed during the first hours after birth b. Transference of immune globulins from the placenta to the infant c. An overwhelming allergic response to an antigen d. A recent exposure to a pathogenic agent

ANS: D Feedback A This is the IgA. B This is the IgG. C This is not associated with elevated levels of IgM. D An elevated level of IgM is associated with exposure to infection in utero because IgM does not cross the placenta.

10. A laboring patient in the latent phase is experiencing uncoordinated, irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger." b. "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain." c. "Let me take off the monitor belts and help you get into a more comfortable position." d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."

ANS: D Feedback A This statement is belittling the patient's complaints. Support and comfort are necessary. B Breathing will not decrease the pain. C It is important to get her into a more comfortable position, but fetal monitoring should continue. D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation.

12. A nurse is responsible for teaching new parents about the hygienic care of their newborn. The nurse should tell the parents to a. Avoid washing the head for at least 1 week to prevent heat loss. b. Sponge bathe only until the cord has fallen off. c. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips. d. Water temperature should be at least 38° C.

ANS: D Feedback A To prevent heat loss, the infant's head should be bathed before unwrapping and undressing. B Tub baths may be initiated from birth. Ensure that the infant is fully immersed. C Q-tips should not be used, because they may cause injury. A corner of a moistened washcloth should be twisted into shape so that it can be used to cleanse the ears and nose. D The ideal temperature of the bath water should be at least 38° C or 100.4° F.

34. Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? a. Varicosities of the legs b. Carpal tunnel syndrome c. Periodic numbness and tingling of the fingers d. Headaches

ANS: D Feedback A Total or nearly total regression of varicosities is expected after childbirth. However, headaches might deserve attention. B Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Headaches, however, might deserve attention. C Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition. Headaches, however, might deserve attention. D Headaches in the postpartum period can have a number of causes, some of which deserve medical attention.

15. Which nursing action must be initiated first when evidence of prolapsed cord is found? a. Notify the physician. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean delivery. d. Reposition the mother with her hips higher than her head.

ANS: D Feedback A Trying to relieve pressure on the cord should be the first priority. B Trying to relieve pressure on the cord should take priority over increasing fetal monitoring techniques. C Emergency cesarean delivery may be necessary if relief of the cord is not accomplished. D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed.

1. Which actions by the nurse may prevent infections in the labor and delivery area? a. Vaginal examinations every hour while the woman is in active labor b. Use of clean techniques for all procedures c. Cleaning secretions from the vaginal area by using back-to-front motion d. Keeping underpads and linens as dry as possible

ANS: D Feedback A Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity. B Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. C Vaginal drainage should be removed with a front-to-back motion to decrease fecal contamination. D Bacterial growth prefers a moist, warm environment.

19. A breastfeeding client who was discharged yesterday calls to ask about a tender hard area on her right breast. What should be the nurse's first response? a. "This is a normal response in breastfeeding mothers." b. "Notify your doctor so he can start you on antibiotics." c. "Stop breastfeeding because you probably have an infection." d. "Try massaging the area and apply heat; it is probably a plugged duct."

ANS: D A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area. Massage of the area followed by heat will cause the duct to open. This is a normal deviation but requires intervention to prevent further complications. Tender hard areas are not the signs of an infection, so antibiotics are not indicated. Fatigue, aching muscles, fever, chills, malaise, and headache are signs of mastitis. She may have a localized area of redness and inflammation. PTS: 1 DIF: Cognitive Level: Application REF: 451 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

16. As the nurse assists a new mother with breastfeeding, the mother asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" The nurse's best response is that it contains: a. more calcium. b. more calories. c. essential amino acids. d. important immunoglobulins.

ANS: D Breast milk contains immunoglobulins that protect the newborn against infection. Calcium levels are higher in formula than breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly. The calorie counts of formula and breast milk are about the same. All the essential amino acids are in formula and breast milk. The concentrations may differ. PTS: 1 DIF: Cognitive Level: Application REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C

ANS: D D&C allows examination of the uterine contents and removal of any retained placental fragments or blood clots. Hysterectomy, laparoscopy, and laparotomy are not indicated.

12. To prevent breast engorgement, what should the new breastfeeding mother be instructed to do? a. Feed her infant no more than every 4 hours. b. Limit her intake of fluids for the first few days. c. Apply cold packs to the breast prior to feeding. d. Breast-feed frequently and for adequate lengths of time.

ANS: D Engorgement occurs when the breasts are not adequately emptied at each feeding or if feedings are not frequent enough. Breast milk moves through the stomach within 1.5 to 2 hours, so waiting 4 hours to feed is too long. Frequent feedings are important to empty the breast and establish lactation. Fluid intake should not be limited with a breastfeeding mother; that would decrease the amount of breast milk produced. Warm packs should be applied to the breast before feedings. PTS: 1 DIF: Cognitive Level: Application REF: 453 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is a. absence of cyanosis in the buccal mucosa. b. cool, dry skin. c. diminished restlessness. d. decreased urinary output.

ANS: D Hemorrhage may result in hypovolemic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised, and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective in nature. The presence of cool, pale, clammy skin is an indicative finding associated with hypovolemic shock. Restlessness indicates decreased cerebral perfusion.

18. Which should the nurse recommend to the postpartum client to prevent nipple trauma? a. Assess the nipples before each feeding. b. Limit the feeding time to less than 5 minutes. c. Wash the nipples daily with mild soap and water. d. Position the infant so the nipple is far back in the mouth.

ANS: D If the infant's mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, causing trauma to the area. Assessing the nipples for trauma is important, but it will not prevent sore nipples. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. Soap can be drying to the nipples and should be avoided during breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 458 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

20. Which is an important consideration about the storage of breast milk? a. Can be thawed and refrozen b. Can be frozen for up to 2 months c. Should be stored only in glass bottles d. Can be kept refrigerated for 48 hours

ANS: D If used within 48 hours after being refrigerated, breast milk will maintain its full nutritional value. It should not be refrozen. Frozen milk should be kept for 1 month only. Antibodies in the milk will adhere to glass bottles. Only rigid polypropylene plastic containers should be used. PTS: 1 DIF: Cognitive Level: Understanding REF: 458 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment

13. What is the difference between the aseptic and terminal methods of sterilization? a. The aseptic method requires a longer preparation time. b. The aseptic method does not require boiling of the bottles. c. The terminal method requires boiling water to be added to the formula. d. The terminal method sterilizes the prepared formula at the same time it sterilizes the equipment.

ANS: D In the terminal sterilization method, the formula is prepared in the bottles, which are loosely capped, and then the bottles are placed in the sterilizer, where they are boiled for 25 minutes. The terminal method takes 25 minutes to boil; the aseptic method takes 5 minutes to boil. With the aseptic method, the bottles are boiled separate from the formula. With the terminal method, the formula is prepared, placed in bottles, and everything is boiled at one time. PTS: 1 DIF: Cognitive Level: Understanding REF: 458 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a. Postpartum depression b. Postpartum psychosis c. Postpartum bipolar disorder d. Postpartum blues

ANS: D Postpartum blues, or "baby blues," is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth. Postpartum depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that postpartum depression is underdiagnosed and underreported. Postpartum psychosis is a rare condition that usually surfaces within 3 weeks of delivery. Hospitalization of the woman is usually necessary for treatment of this disorder. Bipolar disorder is one of the two categories of postpartum psychosis, characterized by both manic and depressive episodes.

One of the first symptoms of puerperal infection to assess for in the postpartum woman is a. fatigue continuing for longer than 1 week. b. pain with voiding. c. profuse vaginal bleeding with ambulation. d. temperature of 38° C (100.4° F) or higher after 24 hours.

ANS: D Postpartum or puerperal infection is any clinical infection after childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth. Fatigue is a later finding associated with infection. Pain with voiding may indicate a UTI, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.

17. What should the nurse explain when responding to the question, "Will I produce enough milk for my baby as she grows and needs more milk at each feeding?" a. Early addition of baby food will meet the infant's needs. b. The breast milk will gradually become richer to supply additional calories. c. As the infant requires more milk, feedings can be supplemented with cow's milk. d. The mother's milk supply will increase as the infant demands more at each feeding.

ANS: D The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Solids should not be added until about 4 to 6 months, when the infant's immune system is more mature. This will decrease the chance of allergy formations. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. PTS: 1 DIF: Cognitive Level: Application REF: 441 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

What teaching does the nurse provide to help new mothers prevent postpartum depression? a. Stay home and avoid outside activities to ensure adequate rest. b. Be the only caregiver for your baby to facilitate infant attachment. c. Keep feelings of sadness and adjustment to your new role to yourself. d. Realize that this is a common occurrence that affects many women.

ANS: D The new mother should understand that postpartum depression is common. Rest is important, but she does not need to confine herself to the house. Others need to help care for the baby so the mother can rest. Women need to be open and discuss their feelings.

Which statement by a postpartum woman indicates that teaching about thrombus formation has been effective? a. "I'll stay in bed for the first 3 days after my baby is born." b. "I'll keep my legs elevated with pillows." c. "I'll sit in my rocking chair most of the time." d. "I'll put my support stockings on every morning before rising."

ANS: D Venous congestion begins as soon as the woman stands up. The stockings should be applied before she rises from the bed in the morning. As soon as possible, the woman should ambulate frequently. The mother should avoid knee pillows because they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities.

1. Although circumcision continues to be a controversial procedure, many parents in the United States elect to have this surgery performed on their newborn sons. It is believed that newborns do not feel pain; therefore this is the optimum time for the procedure to be done and no anesthesia is required. Is this statement true or false?

ANS: F At one time it was thought that newborns felt no pain. It is now known that pain stimuli pass along the fetal pain pathways as early as the second and third trimester. The nurse who assists with this procedure has a number of options available to reduce the pain response for the neonate. These include a dorsal penile block, EMLA, acetaminophen, and sucrose.

2. Clotting factors and fibrinogen levels normally are decreased during pregnancy and remain low in the immediate puerperium. This hypocoagulable state increases the risk of thromboembolism, especially after cesarean birth. Is this statement true or false?

ANS: F Clotting factors and fibrinogen normally are increased during pregnancy and remain elevated in the immediate puerperium. This hypercoagulable state increases the risk of thromboembolism, especially after cesarean birth.

1. Part of the newborn assessment includes examination of the umbilical cord. The cord should contain 2 vessels: one vein and one artery. Is this statement true or false?

ANS: F The umbilical cord contains 3 vessels: two small arteries and one large vein. A 2-vessel cord may be an isolated abnormality or it may be associated with chromosomal and renal defects.

1. The nurse has been caring for a primiparous patient who is suspected of carrying a macrosomic infant. Pushing appears to have been effective so far; however, as soon as the head is born, it retracts against the perineum much like a turtle's head drawing into its shell. In evaluating the labor progress so far, the nurse is aware that this is normal with large infants and extra pushing efforts by the mother may be necessary. Is this statement true or false?

ANS: F This is often referred to as the "turtle sign" and is an indication of shoulder dystocia. Delayed or difficult birth of the shoulders may occur if they become impacted above the maternal symphysis pubis. This complication of birth requires immediate intervention because the umbilical cord is compressed and the chest cannot expand within the vagina. Any of several methods may be employed to relieve the impacted shoulders. Shoulder dystocia is unpredictable and although more common in large infants, can occur with a baby of any weight.

2. In many facilities protocols allow the nurses to obtain transcutaneous bilirubin measurements (TcB) using a bilirubin meter, without the order of a nurse practitioner or physician. Is this statement true or false?

ANS: T Bilirubinometers are non-invasive devices to measure bilirubin levels in the infant's skin, thus avoiding repeated skin punctures to obtain blood samples. Abnormal results of TcB be should be confirmed with a total serum bilirubin (TsB). The National Association of Neonatal Nurses recommends obtaining a TcB or TsB on all infants prior to discharge.

2. An important nursing intervention is maintaining safe glucose levels in the newborn. A common practice is to feed infants either breast milk or formula if glucose screening shows results of 40 to 45 mg/dL or less. Is this statement true or false?

ANS: T Glucose water alone is not recommended for newborns because the rapid rise in glucose, will result in increased in sling production, causing a further drop in the blood glucose level. Milk provides a longer-lasting supply of glucose for the newborn.

1. The nurse evaluating the amount of lochia on a newly delivered patient knows that a moderate amount of flow constitutes a 4- to 6-inch stain on the peripad. Is this statement true or false?

ANS: T Since estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: Scant—less than a 1-inch stain on the peripad Light—a 1- to 4-inch stain Moderate—a 4- to 6-inch stain Heavy—saturated peripad Excessive—saturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth since some of the endometrial lining is removed during surgery.

2. Infant mortality for late preterm infants (34 to 36 weeks) is three times the rate of mortality for term infants. Is this statement true or false?

ANS: T This statement is correct. LPI infants may appear full term at birth; however, the appearance of the infant is deceiving. LPI infants have a mortality risk three times that of term infants for death from all causes.

A nurse is caring for a patient in the active phase of labor. The woman's bag of water spontaneously ruptures. Suddenly the woman complains of dyspnea and appears restless, hypotensive, tachycardic and cyanotic. The nurse immediately suspects: A. Trauma B. Uterine rupture C. Placenta accrete D. Amniotic fluid embolism

D. Amniotic fluid embolism

The nurse notes on the patient's record that the fetal fibronectin results were positive 1 week ago. The nurse is aware that the woman is at risk for A. Urinary infection B. Preterm labor C. Fetal defects D. Fetal hypoxia

B. Preterm labor

PROM with history of placenta previa, at 30 wks gestations, what do you do?

C-Section

A woman who had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. The nurse's priority action should be to A. Reposition the woman with her hips slightly elevated B. Observe for abnormally high uterine resting tone C. Decrease the rate of nonadditive intravenous fluid D. Notify the physician promptly

D. Notify the physician promptly

What action should be initiated to limit hypovolemic shock when uterine inversion occurs? A. Administer oxygen at 4 L/min by nasal cannula. B. Administer an oxytocin drug by intravenous push. C. Monitor the fetal heart rate every 5 minutes. D. Restore circulating blood volume by increasing the intravenous infusion rate.

D. Restore circulating blood volume by increasing the intravenous infusion rate.

During a precipitate labor it is important for the nurse to A. Administer pain medication as soon as possible B. Keep the mother in the birthing position in preparation for the birth C. Remove the external monitoring devices in order to promote comfort D. Stay with the mother at all times to assist with an emergency birth if needed

D. Stay with the mother at all times to assist with an emergency birth if needed

Which patient is at risk for a prolapsed cord? A. Fetal station is engaged. B. Fetus is term and approximated to be about 7 pounds. C. Fetus is a vertex presentation. D. The patient has hydramnios.

D. The patient has hydramnios.