MATERNITY EXAM 4 PRACTICE QUESTIONS
Which instruction about feeding does the nurse give to the parent of a low-birth-weight infant with septicemia? "Don't breastfeed before administering the medications." "You may breastfeed your infant every 3 hours." "Use infant formulas for the first 2 weeks." "You may choose not to breastfeed at all."
"You may breastfeed your infant every 3 hours." Breast milk contains iron-binding proteins that exert a bacteriostatic effect on Escherichia coli. Breast milk also serves as a barrier to infection because it contains macrophages and lymphocytes. The infant can be breastfed every 3 hours to ensure proper rest between the feeding intervals. It is not necessary to stop breastfeeding while administering medications because the medicines do not interact with breast milk. Infant formulas are not advised because they do not contain protective mechanisms against infection. The nurse should encourage the mother to breastfeed because it is beneficial for the infant.
Which ratio would be used to restore effective circulating volume in a postpartum client who is experiencing hypovolemic shock? 4:1 2:1 1:1 3:1
A 3:1 ratio of 3 ml infused for every 1 ml of estimated blood lost is recommended to restore circulating volume.
What instruction does the nurse provide to parents of a preterm infant who has physiologic immaturity? A "The child will have irreparable physiologic deformities." B "The child may be vulnerable to fluid and electrolyte imbalances later. "C "The infant may need neurologic and developmental interventions later." D "The infant will have attention deficit hyperactivity disorder (ADHD)."
A preterm infant may have neurologic impairment after birth, which may result in behavioral and developmental problems later in life. Therefore the nurse instructs the parents that the infant may need neurologic and developmental interventions later. Telling the parents that the infant will have irreparable physiologic deformities will make the parents anxious. There may or may not be any deformities depending on the size and gestational age of infants at birth. Fluid and electrolyte imbalances are caused by fluid overload or dehydration and are treated with appropriate fluid replacement. The child may have ADHD or other neurologic problems, depending on the degree of immaturity at birth. C
Which infant is a likely candidate for receiving exogenous surfactant?An infant with hypoglycemia born to a diabetic mother A preterm infant with a soft cranium who is at risk for cranial molding An infant at risk for inborn errors of metabolism, such as galactosemia A preterm infant with respiratory distress syndrome at birth
A preterm infant with respiratory distress syndrome at birth Exogenous surfactant helps maintain lung expansion in infants with respiratory distress syndrome. Oral glucose is used for an infant with hypoglycemia at birth. A preterm infant is placed on a waterbed or a gel mattress to minimize the risk of cranial molding. Galactosemia is managed by eliminating lactose-containing food and milk from the infant's diet.
The nurse is caring for an infant born after 38 6⁄7 weeks of gestation. Which term would best describe the infant's birth condition? A Preterm infant B Full-term infant C Postterm infant D Late preterm infant
An infant who is born between 39 and 40 weeks of gestation is considered full-term. This infant is born after 38 6⁄7 weeks of gestation, so it is a full-term infant. Preterm infants are those born before the completion of 37 weeks of gestation. Postterm infants are those born after 42 weeks of gestational age. Late preterm infant refers to an infant born between 34 and 36 6⁄7 weeks of gestation. B
A postpartum client with hemorrhagic shock has been administered intravenous (IV) infusion of crystalloid solution. Upon reviewing the client's laboratory reports, the nurse finds that platelet count and clotting factor levels are not improved. What is the best treatment option in this situation? 1Infusion of fresh frozen plasma 2Provide supplemental oxygenation 3Administer packed red blood cells 4Increase the dose of crystalloid solution
Answer: 1 When a postpartum client has excessive bleeding due to hemorrhagic shock, an IV infusion of crystalloid solution is administered. If the platelet count is not restored even after the crystalloid IV infusion process, then fresh frozen plasma has to be infused. Fresh frozen plasma contains all the coagulation factors and it helps to restore platelet counts. Packed RBCs are administered if the client has active bleeding, despite the initial crystalloid administration. Increasing the dose or volume of crystalloid solution will not increase the levels of clotting factors and platelets. Supplementary oxygenation is given to compensate for the reduced tissue perfusion when the client has hypovolemic shock. Supplementary oxygenation does not increase the levels of clotting factors and platelets.
Which medication is contraindicated in a client who is on anticoagulant therapy?1Aspirin (Ecotrin)2Clindamycin (Cleocin)3Misoprostol (Cytotec)4Ergonovine (Ergotrate)
Answer: 1Aspirin (Ecotrin) is contraindicated in clients undergoing anticoagulant therapy, because it inhibits the synthesis of clotting factors and can lead to prolonged clotting time. Clindamycin (Cleocin) does not inhibit the synthesis of clotting factors and can be administered in clients undergoing anticoagulant therapy. Misoprostol (Cytotec) and ergonovine (Ergotrate) do not affect the clotting factors and do not interact with anticoagulants. Thus, it is safe to administer misoprostol (Cytotec) and ergonovine (Ergotrate) to clients undergoing anticoagulant therapy.
Which postpartum conditions are considered medical emergencies that require immediate treatment?1Inversion of the uterus and hypovolemic shock 2Hypotonic uterus and coagulopathies 3Subinvolution of the uterus and idiopathic thrombocytopenic purpura 4Uterine atony and coagulopathies
Answer: 1Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic uterus can be managed with massage and oxytocin. Coagulopathies should be identified before birth and treated accordingly. Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment. ITP can be safely managed with corticosteroids or IV immunoglobulin. DIC and uterine atony are very serious obstetric complications; however, uterine inversion is a medical emergency requiring immediate intervention.
The postpartum client who delivered a day ago reports, "I feel tired very often and experience pain in my lower abdomen." Upon further observation, the nurse finds that the client also has profuse foul-smelling vaginal discharge and an increased pulse. Which medication would be added to the client's prescription?1Warfarin (Coumadin) 2Clindamycin (Cleocin) 3Misoprostol (Cytotec) 4Ergonovine (Ergotrate)
Answer: 2 Endometrial infection is characterized by tiredness and lower abdominal pain, profuse foul-smelling discharge, and increased pulse. Clindamycin (Cleocin) is an antibiotic used to treat endometrial infections. Warfarin (Coumadin) is prescribed to postpartum clients with thromboembolic disorders. Misoprostol (Cytotec) is prescribed to clients with excessive bleeding caused by uterine atony. Ergonovine (Ergotrate) is prescribed to treat subinvolution of the uterus.
What is the primary cause of thromboembolic disease? 1Viral infection 2Hypercoagulation 3Corticosteroid therapy 4Deficient clotting factor
Answer: 2 Hypercoagulation and venous state are the primary causes for thromboembolic disease. Thromboembolic disease is characterized by the formation of clots in the blood vessel mainly due to inflammation. Viral infection is not associated with the formation of clots. Administration of corticosteroids does not alter the clotting behavior in a patient. Deficiency of clotting factors results in bleeding; it is not associated with thromboembolic disease.
The nurse is assessing a client with postpartum hemorrhage (PPH). During the physical assessment, the nurse finds that there are deep lacerations in the cervix. Which observation allows the nurse to conclude that the PPH is due to cervical lacerations? 1Dark red blood 2Bright red blood 3Clots in the blood 4Foul-smelling blood
Answer: 2 If the color of blood is bright red, it indicates that hemorrhage has occurred due to deep lacerations of the cervix. Foul-smelling blood during the postpartum period indicates infection. Bleeding due to varices or superficial lacerations of the birth canal is dark red in color. Clots in the blood characterize the PPH caused by disseminated intravascular coagulation (DIC).
Which hematologic disorder is transferred genetically from parents to offspring? 1Deep vein thrombosis 2von Willebrand disease 3Superficial vein thrombosis 4Idiopathic thrombocytopenia
Answer: 2Von Willebrand disease is a hereditary disorder. It is a type of hemophilia caused by the deficiency of ablood clotting factor called von Willebrand factor. Deep vein thrombosis is not a hereditary disorder. It is caused by inflammation or partial obstruction of deep veins in the lower limb. Superficial vein thrombosis is not a hereditary disorder. It is caused by the inflammation or obstruction of superficial veins of the lower limb. Idiopathic thrombocytopenia is an autoimmune disorder. It is not transferred from parents to offspring.
Which postpartum infection is most often contracted by first-time mothers who are breastfeeding? 1Endometritis 2Wound infections 3Mastitis 4Urinary tract infections (UTIs)
Answer: 3 Mastitis is an infection in a breast, usually confined to a milk duct. Most women who suffer this are first-time mothers who are breastfeeding. Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth and not limited to first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal examinations, and epidural anesthesia.
Which postpartum infection is most often contracted by first-time mothers who are breastfeeding?1Endometritis 2Wound infections 3Mastitis 4Urinary tract infections (UTIs)
Answer: 3 Mastitis is an infection in a breast, usually confined to a milk duct. Most women who suffer this are first-time mothers who are breastfeeding. Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth and not limited to first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal examinations, and epidural anesthesia.
What is the first and most important nursing intervention when a nurse observes profuse postpartum bleeding?1Call the woman's primary health care provider 2Administer the standing order for an oxytocic 3Palpate the uterus and massage it if it is boggy 4Assess maternal blood pressure and pulse for signs of hypovolemic shock
Answer: 3 The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. The most important nursing intervention is to stop the bleeding. Once the nurse has applied firm massage of the uterine fundus the primary health care provider should be notified or the nurse can delegate this task to another staff member. Administering the standard order for an oxytocic is appropriate after assessment and immediate steps have been taken to control the bleeding. Vital signs will need to be ascertained after fundal massage has been applied.
After reviewing the medical reports of a client, the nurse finds that the client has multifetal gestation. What could be the most likely complication associated with this? 1Vaginal hematomas 2Von Willebrand disease (vWD) 3Postpartum hemorrhage (PPH )4Abnormal development of limbs
Answer: 3 The uterine walls are overstretched due to multifetal gestation, so the uterus contracts poorly after birth. This may cause uterine atony, leading to PPH. Multifetal gestation does not cause vaginal hematomas, vWD, or abnormal limb development of the fetus. Vaginal hematomas occur more commonly in association with a forceps-assisted birth. vWD is a type of hemophilia, which is a hereditary bleeding disorder. Abnormal development of fetal limbs is usually a complication associated with teratogenic drugs.
Which medication is contraindicated in a client who is on anticoagulant therapy?
Aspirin (Ecotrin) Aspirin (Ecotrin) is contraindicated in clients undergoing anticoagulant therapy, because it inhibits the synthesis of clotting factors and can lead to prolonged clotting time.
The nurse is assessing a postpartum client 4 hours after delivery. The nurse observes that the client has cool, pale, and clammy skin with severe restlessness and thirst. What should the immediate nursing intervention be? Begin fundal massage and start oxygen therapy. Begin an hourly pad count and reassure the client. Elevate the head of the bed and assess vital signs. Assess for hypovolemia and notify the primary health care provider.
Assess for hypovolemia and notify the primary health care provider.
Thromboembolic conditions that are of concern during the postpartum period include (Select all that apply.) A) Amniotic fluid embolism (AFE) B) Superficial venous thrombosis C) Deep vein thrombosis D) Pulmonary embolism E) Disseminate intravascular coagulation (DIC)
B) Superficial venous thrombosis C) Deep vein thrombosis D) Pulmonary embolism Rationale:An AFE occurs during the intrapartum period when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs. DIC is an imbalance between the body's clotting and fibrinolytic systems. It's a pathologic form of clotting that consumes large amounts of clotting factors.
Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect:bladder distention.uterine atony.constipation.hematoma formation. Correct
Bladder distention would result in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony would result in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.
A 28-year-old multipara delivered a 9 pound, 3 ounce baby girl an hour ago after a 22-hour labor with a forceps-assisted birth. As the patient is holding her daughter, she keeps shifting position and is becoming increasingly irritable and annoyed with everyone in the room. What action should the nurse initially take? Massage the fundus Check her perineum. Assess her vital signs. Check the tone of her fundus.
Check her perineum. The client is exhibiting increasing anxiety, which can signal the presence of postpartum hemorrhage. Risk factors for postpartum hemorrhage include a large fetus, prolonged labor, and a forceps-assisted birth. Because vital signs change late, the fastest way to see the amount of current hemorrhage is to check the perineum. The fundus would be massaged and additional nursing and medical interventions would be instituted.
the nurse finds that she has endometritis. Which medication should be involved in the treatment plan of this client?
Clindamycin (Cleocin)
What are premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration experiencing? A Suffering from sleep or wakeful apnea B Experiencing severe swings in blood pressure C Trying to maintain a neutral thermal environment D Breathing in a respiratory pattern common to premature infants
D Breathing in a respiratory pattern common to premature infants
Which conditions is the nurse alert for in a preterm infant with respiratory distress syndrome?
Hypoxemia Metabolic acidosis
The nurse is caring for a neonate with intrauterine growth restriction (IUGR). The nurse observes that the neonate is restless, lethargic, and hypothermic. What immediate intervention does the nurse provide to ensure the neonate's safety? A Administer water feeding. B Provide ventilator support. C Stop formula feeding for 2 days. D Immediately assess the newborn's blood sugar level.
IUGR causes restricted growth patterns in the neonate, resulting in complications like hypoglycemia and polycythemia. Reduced body temperature (hypothermia) is characteristic of hypoglycemia. Restlessness and lethargy are other symptoms that indicate hypoglycemia. The nurse should immediately assess the blood sugar levels, and administer dextrose the blood sugar is found to be less. Water feeding is avoided in neonates, as it may cause water intoxication. Ventilator support is provided in the case of neonatal respiratory depression. Immediate formula feed or mother's milk should be encouraged for neonates with hypoglycemia. D
After massaging the boggy fundus of a client who delivered a large baby after a prolonged labor with a forceps-assisted birth, the nurse is unable to obtain a firm fundus. What nursing action is indicated at this time? Increase the rate of the intravenous infusion. Massage the fundus while another nurse notifies the PCP. Change the peripad, replacing it with a double pad. Administer a half-dose of a uterine contracting medication.
Massage the fundus while another nurse notifies the PCP.
The nurse is caring for a preterm infant who needs to have gavage feedings started and requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for insertion of a nasogastric tube in a preterm infant. 1.Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. 2.Lubricate the tip of the tube with sterile water. 3.Gently insert the NG tube through the mouth or nose. 4.Check placement of the NG tube by aspirating gastric contents.
Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. Lubricate the tip of the tube with sterile water. Gently insert the NG tube through the mouth or nose. Check placement of the NG tube by aspirating gastric contents. The infant is place in a supine position. The NG tube is measured from the tip of the nose to the earlobe and to midpoint between the xiphoid process and the umbilicus. Tape may be used to mark the correct length on the tube. The tip of the tube is lubricated with sterile water and then is inserted through the mouth or nose. Placement of the tube is checked by aspirating gastric contents.
After assessing the high risk infant's skin, the nurse documents that the infant has a low neonatal skin condition score (NSCS). Which nursing interventions would ensure that the infant's skin remains intact without any evidence of irritation?
Monitor the use of heating pads and warmers carefully. Clean the skin with plain warm water and apply a moisturizer. Apply a transparent elastic film between tape and skin while securing an intravenous line.
The nurse is caring for a newborn with meconium aspiration syndrome (MAS) who is administered a synthetic surfactant. What interventions should the nurse perform to ensure the safety of the newborn? Multiple selection question
Monitor urinary output. Monitor hematocrit levels. Monitor arterial blood gas (ABG) levels
A nurse providing care to preterm infants should understand that nasogastric and orogastric tubes are used to assist in what? A Help maintain body temperature B Provide oxygen and ventilation C Replace surfactants D Feed the infant
Nasogastric and orogastric tubes are used in gavage feeding, providing breast milk or formula directly to an infant unable to nipple feed. Nasogastric and orogastric tubes are not used in order to help maintain body temperature. This infant should be placed on a warmer. Nasogastric and orogastric tubes cannot provide O2 and ventilation. Supplemental oxygen, continuous positive airway pressure (CPAP), and a ventilator are used for O2 and ventilation. Surfactants are not replaced by using nasogastric or orogastric tubes. D
A client who is 32 weeks pregnant visits a maternal clinic for a routine health checkup. The ultrasound and magnetic resonance imagining (MRI) reveal that the woman is at risk of placenta accreta. Which intervention should be performed during the delivery to ensure client's safety? Blood transfusion Hysterectomy after delivery Natural removal of the placenta Administration of uterine contractile drugs
Natural removal of the placenta
The nurse places a newborn weighing 1400 g in a polyethylene bag. Why would the nurse do this? A To prevent heat loss. B To prevent infections. C To avoid electrolyte loss. D To avoid bluish discoloration.
Newborns weighing 1400 g are considered very low birth weight babies, and these infants are at a higher risk for hypothermia. Therefore, the nurse places the newborn in a polyethylene bag to decrease heat and water loss. The nurse should constantly monitor the neonate for an increase in body temperature to assess if the infant is developing an infection. The nurse administers antibiotics as ordered by the primary health care provider to treat infections. Total parenteral nutrition (TPN) is administered to avoid electrolyte loss in newborns and is unrelated to polyethylene bags. Using a polyethylene bag is not useful for improving the oxygen saturation levels in the baby. Therefore, its use would not help to prevent cyanosis or bluish discoloration. A
postpartum client is bleeding continuously and excessively due to uterine atony. Which medications administered to the client may cause postpartum hemorrhage? Oxytocin (Picotin) Halothane (Fluothane) Nitrous oxide (Anesoxyn) Nitroglycerine (Nitrostat)Magnesium sulfate (Generic
Oxytocin (Picotin) Halothane (Fluothane) Magnesium sulfate (Generic)
What observations of arterial blood gas (ABG) analysis indicate the need for hood therapy for a neonate?Multiple selection question
PaO 2 of 55 mm Hg Oxygen saturation of 85%
Upon assessing a client who is in the third stage of labor, the nurse notices that the client is experiencing vaginal bleeding with spurts of blood and clots. What does the nurse believe is the cause of the bleeding? Deep cervical laceration Intravascular coagulation Superficial vaginal laceration Partial placental separation
Partial placental separation
After reviewing the medical reports of a client, the nurse finds that the client has submucosal uterine fibroids. Which postpartum complication of pregnancy is the client likely to have? Placenta accretaImpaired lactationVaginal hematomas Postpartum hemorrhage
Placenta accreta is a slight penetration of the placenta into the myometrium of the uterus. The clientwho has submucosal fibroids has a higher risk of developing placenta accreta. The symptom of placenta accreta can be diagnosed before birth using an ultrasound and magnetic resonance imaging (MRI). Submucosal fibroids do not have any effect on lactation. Therefore, they do not pose a risk of impaired lactation in the client. Vaginal hematomas are associated with forceps-assisted birth, episiotomy, or primigravidity. Submucosal uterine fibroids do not have any effect on the integrity of the vaginal walls. Therefore, submucosal uterine fibroids do not cause vaginal hematomas. The client's reports suggests that the placenta is adherent to the uterine wall. This does not indicate that the client is at risk of postpartum hemorrhage.
Which term is used to describe perforation of the uterus due to placental adherence to the uterine walls? Placenta previa Placenta increta Placenta accreta Placenta percreta
Placenta percreta
What are the risk factors for necrotizing enterocolitis (NEC) in preterm infants?Multiple selection question
Polycythemia Myelomeningocele
After reviewing the medical reports of a client, the nurse finds that the client has multifetal gestation. What could be the most likely complication associated with this? Vaginal hematomas Von Willebrand disease (vWD) Postpartum hemorrhage (PPH) Abnormal development of limbs
Postpartum hemorrhage (PPH)
A client diagnosed with placenta accreta has uncontrolled bleeding, despite administering medications. What should be the best choice for treatment in this situation? Massage the uterus Prepare the client for surgery Replace blood components as needed Apply traction on the umbilical cord
Prepare the client for surgery Placenta accreta is an obstetric complication in which the placenta adheres to and penetrates the myometrium. The patient with placenta accreta is at risk of having hemorrhage during childbirth. If bleeding is not stopped after the administration of medication to the client, then a hysterectomy has to be performed to prevent further complications. Replacement of blood components is not useful, because the client has uncontrolled bleeding. Massaging the uterus and applying traction to the umbilical cord is helpful to expel the placenta, but is not useful when the placenta is adhered to the uterus.
Which of the following increase the risk of preterm infants developing hematologic problems?
Prolonged PT time Decreased red blood cell survival time Decrease in erythropoiesis
Which interventions does the nurse incorporate in the plan of care to comfort the parents after the death of their preterm infant?
Provides privacy for the family Talks about the infant or attending the funeral Notifies a member of the clergy if the parents desire
The nurse is caring for an infant born at 28 weeks of gestation. Which complication can the nurse expect to observe during the course of the infant's hospitalization? Multiple selection question
Respiratory distress syndrome Periventricular hemorrhage Patent ductus arteriosus
A client who has undergone cesarean surgery reports to the nurse about having persistent perineal pain and feels pressure in the vagina. The nurse finds that the client is in shock. What clinical condition should the nurse suspect based on this assessment?Rectocele. Endometritis. Impaired lactation. Retroperitoneal hematoma.
Retroperitoneal hematoma. Accumulation of blood in the retroperitoneal space is called retroperitoneal hematoma. It is caused by the rupture of the cesarean scar during labor. Retroperitoneal hematoma is characterized by such symptoms as persistent perineal pain, a feeling of pressure in the vagina, and shock. Therefore it is evident that the client has this condition. Persistent perineal pain, a feeling of pressure in the vagina, and shock are not associated with rectocele, endometritis, and impaired lactation. Rectocele is the herniation of the anterior rectal wall through the relaxed or ruptured vaginal fascia and rectovaginal septum. Endometritis is characterized by fever, increased pulse rate, chills, anorexia, nausea, fatigue, pelvic pain, uterine tenderness, and foul-smelling lochia. Because the client did not report these symptoms, the client does not have endometritis. Perineal pain, a feeling of pressure in the vagina, and shock do not affect lactation, so the client does not have impaired lactation.
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include what? A Hypertonia, tachycardia, and metabolic alkalosis. B Abdominal distention, temperature instability, and grossly bloody stools. C Hypertension, absence of apnea, and ruddy skin color. D Scaphoid abdomen, no residual with feedings, and increased urinary output.
Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis. Hypotension, apnea, and pallor are signs of NEC. Abdominal distention, residual gastric aspirates, and oliguria are signs of NEC. B
While performing a physical examination of a postpartum client, the nurse finds that the uterus is firm and contracted. The client reports dark red lochial discharge. Which treatment strategy may help prevent further complications in the client? Tocolytics Stool softeners Anticoagulants Halogenated anesthetics
Stool softeners
While assessing a postpartum woman, the nurse finds dark red blood coming from the vagina. What can the nurse infer about the client's condition by observing the blood's color? The client has partial placental separation. The client has a deep laceration of the cervix. The client has superficial lacerations of the birth canal. he client has disseminated intravascular coagulation (DIC).
Superficial lacerations of the birth canal are characterized by dark red blood oozing from the vagina. The dark red color indicates its venous origin. Partial placental separation is characterized by spurts of blood with clots. Deep laceration of the cervix is characterized by bright redarterial blood. DIC is a condition in which the blood fails to clot or remain clotted. If the client had DIC, the color of the vaginal blood would be bright red.
An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: A. Birth injury. B. Hypocalcemia. C. Hypoglycemia. D. Seizures.
The description is indicative of a macrocosmic infant. Hypoglycemia is common in the infant with macrosomia. The tremors are jitteriness that is associated with hypoglycemia. Other signs of hypoglycemia are apnea, tachypnea, and cyanosis. C
The nurse is caring for a preterm infant who needs to have gavage feedings started and requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for insertion of a nasogastric tube in a preterm infant.
The infant is placed in a supine position. The NG tube is measured from the tip of the nose to the earlobe and to midpoint between the xiphoid process and the umbilicus. Tape may be used to mark the correct length on the tube. The tip of the tube is lubricated with sterile water and then is inserted through the mouth or nose. Placement of the tube is checked by aspirating gastric contents.
The nurse is caring for an infant with a body temperature of 34°C and a body weight of 1400 g. What other parameter is most important to monitor to prevent complications related to low birth weight? A Increased urinary output B Decreased respiratory rate C Cold extremities D Golden brown patches on skin
The normal birth weight of an infant should be more than 2500 g and the normal body temperature should be 36°C. A birth weight of 1400 g indicates low birth weight and temperature less than 35°C signifies that the infant has hypothermia. The nurse maintains the infant's body temperature by generating heat using radiant heaters. Heat generation increases the oxygen consumption in the infant, which may result in hypoxia. Therefore, the nurse should monitor the infant's respiratory rate. Decreased respiratory rate causes respiratory depression (RD). Increased urinary output is observed when the infant is administered dextrose for hyperglycemia. Hypothermia is characterized by cold extremities. Golden brown patches on the skin are usually observed in postpartum infants and are unrelated to hypothermia. B
The nurse finds that despite gentle traction to the umbilical cord and uterine massage, the client's placenta has not expelled out even after 30 minutes of childbirth. The primary health care provider instructs the nurse to administer nitroglycerin IV (Nitrostat) to the client. What could be the reason for this instruction? Prevention pelvic hematoma To increase the effects of regional anesthesia To promote uterine relaxation Prevention of postpartum hemorrhage
To promote uterine relaxation
The nurse is caring for an infant born after 38 6⁄7 weeks of gestation. Which term would best describe the infant's birth condition?
full-term infant An infant who is born between 39 and 40 weeks of gestation is considered full-term. This infant is born after 38 6⁄7 weeks of gestation, so it is a full-term infant. Preterm infants are those born before the completion of 37 weeks of gestation. Postterm infants are those born after 42 weeks of gestational age. Late preterm infant refers to an infant born between 34 and 36 6⁄7 weeks of gestation.
Advancing Infant Feedings
• Weaning off parenteral nutrition- Nourishment given by continuous or intermittent gavage feedings increased- Parenteral fluids decreased- MEN to stimulate GI system to mature and enhance caloric intake • Advanced slowly and cautiously because if advanced too rapidly, infant can develop V/D, abdominal distention, and apneic episodes • Rapid advancements in volume of feeds implicated as a risk factor for NEC- Can also cause fluid retention with cardiac compromise or a pronounced diuresis with hyponatremia • Need for additional calories: commercial human milk fortifer added to gavage breast milk, or # of calories per 30mL of commercial formula can be increased • Microbore tubing used for both continuous and intermittent gavage feedings to decrease the problem of lost calories in breast milk when cream separates and adheres to tubing • Gavage feeding => bottle or breast milk feeding- Gavage feedings are decreased as infant's ability to suckle breast milk or formula improves • Indwelling tube during breast or bottle feedings = increased respiratory effort
