NCLEX Prep: PN Maternal and Newborn

Uterine Rupture

a tear in the wall of the uterus

Molar Pregnancy

also known as gestational trophoblastic disease; abnormal proliferation of trophoblastic cells in the first trimester

Leopold Maneuver

external palpation of the maternal abdomen to determine fetal lie, presentation, attitude, and position

Placenta Previa

implantation of the placenta over the cervical opening or in the lower region of the uterus

abruptio placentae

premature separation of the placenta from the uterine wall

Uterine Tachysystole

more than five contractions in 10 minutes, averaged over a 30-min window

GERD (gastroesophageal reflux disease)

A digestive disease in which stomach acid or bile irritates the food pipe lining.

Nonstress test

A method for evaluating fetal status during the antepartum period by observing the response of the fetal heart rate to fetal movement.

The nurse is obtaining a client's history during an initial prenatal visit. The client's last menstrual period was from March 1 to March 5. Unprotected intercourse occurred on March 15. Slight vaginal spotting was noted on March 23. The client's menstrual cycles are regular and 28 days long. Using the Nägele rule, what is the estimated date of birth? A. December 8 B. December 12 C. December 22 D. December 30

Correct Answer: A. December 8 Establishing an estimated date of birth (EDB) is important because many decisions and interventions during pregnancy are based on this information (eg, labor induction, diagnosing preterm labor). Methods to determine EDB include the Nägele rule, ultrasound, fundal height measurement, and fetal heart rate auscultation via handheld Doppler monitor (at ~10 weeks gestation). The Nägele rule uses a standard formula based on the last normal menstrual period (LMP) to determine EDB based on a 28-day menstrual cycle: EDB = (LMP − 3 months) + 7 days. · First day of LMP: March 1 · Subtract 3 months: December 1 · Add 7 days: December 8 This client's EDB is December 8 Incorrect Answer: [B. December 12] December 12 was calculated using the last day of the client's menses (March 5). Menses length can vary, so the last day of menses cannot be used to accurately calculate EDB. [C. December 22] December 22 was calculated based on the likely date of conception (March 15). Because the timing of ovulation varies by client, this is not an accurate method for calculating EDB. [D. December 30] December 30 was calculated using the client's report of vaginal spotting (March 23). Light vaginal spotting may be noted when the trophoblast implants into the endometrium. Many clients confuse "implantation bleeding" for an unusually light period. Dating a pregnancy from this day is inaccurate. Educational objective:The Nägele rule is a standard formula based on the last normal menstrual period (LMP) that determines the estimated date of birth (EDB) based on a 28-day menstrual cycle: EDB = (LMP − 3 months) + 7 days.

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply. A. Anticipate light fetal movements around 16-20 weeks gestation B. Expect to have an abdominal ultrasound for fetal anatomy evaluation C. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal D. Increase consumption of iron-rich foods like meat and dried fruit E. Plan for gestational diabetes screening near the end of the second trimester

Correct Answers: A, B, C, D, and E The second trimester (14 wk 0 d to 27 wk 6 d) is a time of positive changes for many pregnant clients (eg, improved nausea) and when physical evidence of the pregnancy is noted (eg, increased fundal height). The nurse should prepare clients for expected physical changes and discuss prevention of potential complications. · Quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestation, depending on parity. · Weight gain increases by approximately 1 lb (0.5 kg) per week if pre-pregnancy BMI has been normal. · Increasing intake of iron-rich foods (eg, meat, dried fruit) and continuing prenatal vitamins both help to prevent anemia caused by increased fetal iron requirements after 20 weeks gestation. · Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation. The nurse should also discuss routine screening/diagnostic tests performed during the second trimester. · An ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta. · Screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (ie, 1-hour glucose challenge test). GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance. Educational objective:During the second trimester, the nurse should provide guidance regarding fetal movements, weight gain, screening/diagnostic tests (eg, fetal anatomy ultrasound, 1-hour glucose challenge test), and increased requirements for iron to maintain maternal and fetal health.

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply. A. Blood pressure 82/64 mm Hg B. Crackles on auscultation C. Distended jugular veins D. Pulse 120/min E. Shoulder pain

Correct Answers: A, D, and E Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity. The majority of ectopic pregnancies occur in the fallopian tubes. Risk factors include recurrent sexually transmitted infections, tubal damage or scarring, intrauterine devices, and previous tubal surgeries (eg, tubal ligation for sterilization). Clinical manifestations are lower-quadrant abdominal pain on one side, mild to moderate vaginal bleeding, and missed or delayed menses. Signs of subsequent hypovolemic (hemorrhagic) shock from ruptured ectopic pregnancy include dizziness, hypotension, and tachycardia. Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. Peritoneal signs (eg, tenderness, rigidity, low-grade fever) may develop subsequently. Incorrect Answer: [B. Crackles on auscultation] Distended jugular veins and lung crackles indicate volume overload. The main risk with ectopic pregnancy is hypovolemic (hemorrhagic) shock. Jugular veins would be flat in hypovolemic shock. [C. Distended jugular veins] Distended jugular veins and lung crackles indicate volume overload. The main risk with ectopic pregnancy is hypovolemic (hemorrhagic) shock. Jugular veins would be flat in hypovolemic shock. Educational objective:The fallopian tubes are the most common site for an ectopic pregnancy. As the ectopic pregnancy grows and expands, rupture may occur, resulting in active bleeding that progresses to life-threatening hypovolemic (hemorrhagic) shock. Signs of ruptured ectopic pregnancy may include severe abdominal pain, dizziness, and referred shoulder pain.

Mcroberts Maneuver

sharp flexion of the maternal hips that decreases the inclination of the pelvis increasing the AP diameter of the free anterior shoulder

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply. A. Assist maternal pushing efforts by applying fundal pressure during each contraction B. Document the time the fetal head was born C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis D. Prepare for a forceps-assisted birth E. Request additional assistance from other nurses immediately

Correct B, C, and E Shoulder dystocia is an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis. Shoulder dystocia lasting ≥5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing adverse outcomes (eg, hypoxia, nerve injury, death). When shoulder dystocia occurs, the primary nursing interventions include: · Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers) · Verbalizing passing time to guide decision-making by the health care provider (eg, "two minutes have passed") · Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure) · Requesting additional help from staff (eg, nurses, neonatologist) immediately Incorrect Answers: [A. Assist maternal pushing efforts by applying fundal pressure during each contraction] Fundal pressure and the use of forceps or a vacuum to facilitate birth are contraindicated because they may further wedge the fetal shoulder into the maternal symphysis pubis and increase the risk for neurological complications (eg, brachial plexus injury) in the newborn. [D. Prepare for a forceps-assisted birth] Fundal pressure and the use of forceps or a vacuum to facilitate birth are contraindicated because they may further wedge the fetal shoulder into the maternal symphysis pubis and increase the risk for neurological complications (eg, brachial plexus injury) in the newborn. Educational objective:Shoulder dystocia occurs when the anterior shoulder becomes wedged behind or under the maternal symphysis pubis. The nurse should document the timing of events (eg, birth of fetal head), verbalize passing time, perform McRoberts maneuver, apply suprapubic pressure, and request additional assistance.

Contraindications for breastfeeding

HIV+ or CMV+ mamma (esp for preemies) maternal septicemia, TB, malaria, typhoid fever, breast cancer, ETOH/Drug abuse

Uterine inversion

Is a condition in which the uterus turns inside out and can be caused by the placenta being removed too vigorously prior to its natural detachment process.

Fetal Station

Location of the presenting part in relation to the midpelvis or ischial spines; expressed as cm above or below the spines; station 0 is engaged, station -2 is 2 cm above the ischial spines

Lochia

vaginal discharge after childbirth

Which meal should the nurse recommend for a pregnant client at 13 weeks gestation? A. Baked chicken, turnip greens, peanut butter cookie, and grape juice B. Baked swordfish, fries, baked apples, and fat-free milk C. Chilled ham and cheese sandwich, broccoli, orange slices, and water D. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water

Correct Answer: A. Baked chicken, turnip greens, peanut butter cookie, and grape juice During pregnancy, it is important for the client to consume a balanced diet with appropriate nutrients, vitamins, and minerals. Foods containing folic acid, protein, whole grains, iron, and omega-3 fatty acids are especially important. Due to the risk for bacterial contamination (eg, Listeria, toxoplasmosis), pregnant clients should avoid consuming unpasteurized milk products, unwashed fruits and vegetables, deli meat and hot dogs (unless heated until steaming hot), and raw fish/meat. They should also avoid intake of fish high in mercury (eg, shark, swordfish, king mackerel, tilefish). Incorrect Answers: [B. Baked swordfish, fries, baked apples, and fat-free milk] This meal contains swordfish, which is high in mercury and should be avoided during pregnancy. [C. Chilled ham and cheese sandwich, broccoli, orange slices, and water] This meal contains cold deli meat, which should be avoided during pregnancy due to the risk of listeriosis from Listeria monocytogenes. [D. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water] Liver should be avoided during pregnancy due to high amounts of vitamin A. Although liver is a good source of iron, the excessively high amounts of vitamin A can be teratogenic. Educational objective:An appropriate diet is essential to meet the needs of the pregnant client and growing fetus. Pregnant clients should avoid deli meats and hot dogs (unless steaming hot), liver, unpasteurized milk products, unwashed fruits and vegetables, raw fish, and fish high in mercury.

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct? A. The client had 1 birth at 37 wk 0 d gestation or beyond B. The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation C. The client has 3 currently living children D. The client is currently not pregnant

Correct Answer: A. The client had 1 birth at 37 wk 0 d gestation or beyond The GTPAL system is a shorthand system of documenting a client's obstetric history. This client (G5T1P2A1L2) has been pregnant 5 times (G5); had 1 term birth (T1), 2 preterm births (P2), and 1 abortion (A1); and has 2 currently living children (L2). The client's term birth is indicated by the T1 portion of the GTPAL notation. Incorrect Answers: [B. The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation] The client had 2 preterm births, indicated by the P2 portion of the GTPAL notation. [C. The client has 3 currently living children] The client has 2 currently living children, as indicated by the L2 portion of the GTPAL notation. If a child born full- or preterm is not living (due to stillbirth from 20 wk 0 d and beyond or infant/child death after birth), that birth and subsequent death is counted toward T or P (term or preterm) but is not notated under L (currently living children); T and P record total number of births without regard to current living status. This client has 2 currently living children (L2), which is 1 less than the client's total notation for term + preterm (T1 + P2 = 3). Therefore, the client has experienced the death of 1 child who had been born at 20 wk 0 d gestation or beyond. [D. The client is currently not pregnant] If a client is currently pregnant, the number of pregnancies (gravida) will be greater than the number of births (term, preterm, and abortions combined). This client is a G5, and T1 + P2 + A1 = 4. Therefore, the client is currently pregnant. Educational objective:The GTPAL system notational components are G - gravida (number of pregnancies, regardless of outcome and including current pregnancies), T - term (37 wk 0 d gestation and beyond), P - preterm (20 wk 0 d through 36 wk 6 d gestation), A - abortions (before 20 wk 0 d gestation; spontaneous or induced), and L - currently living children.

A client at 34 weeks gestation has constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which instructions should the nurse reinforce for this client? Select all that apply. A. Decrease total daily dairy intake B. Increase intake of fruits and vegetables C. Moderate-intensity regular exercise D. One laxative twice daily for a week E. Two cups of hot coffee each morning

Correct Answer: B and C Constipation is a common discomfort of pregnancy and is due to an increase in the hormone progesterone, which causes decreased gastric motility. Ferrous sulfate (iron) supplementation may also cause constipation. Interventions to prevent or treat constipation include: 1. High-fiber diet: High amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes 2. High fluid intake: 10-12 cups of fluid daily 3. Regular exercise: Moderate-intensity exercise (eg, walking, swimming, aerobics) 4. Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin Incorrect Answer: [A. Decrease total daily dairy intake] Dairy is a great source of calcium, which is essential for fetal bone development. However, dairy products should be consumed at least 2 hours before or 1 hour after iron supplements as they bind to iron and decrease absorption. [D. One laxative twice daily for a week] Laxatives are not recommended during pregnancy due to the risk of dehydration and electrolyte imbalance, which can lead to uterine cramping and contractions. The client should consult with the health care provider before using any over-the-counter stool softeners or laxatives. [E. Two cups of hot coffee each morning] Caffeine consumption in pregnancy should be limited to 200-300 mg/day. Coffee may contain 100-200 mg caffeine per cup and should therefore be consumed in moderation during pregnancy. Educational objective:Constipation in pregnancy may be caused by increased progesterone levels and iron supplementation. It is best treated with 10-12 cups of fluid daily, a high-fiber diet/supplementation, and regular exercise. Clients should not take laxatives without first discussing this with the health care provider.

A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply. A. Desire for adoption planning services B. Emotional response to the pregnancy C. Family/social support systems D. Nutritional habits and substance abuse E. Plan for finishing high school

Correct Answer: B, C, and D Pregnant adolescent clients are a unique population because of their increased risk for complications during pregnancy (eg, low birth weight, preterm birth, preeclampsia) and developmental needs. During an initial encounter with a pregnant adolescent, the nurse should discuss the client's emotional response to the pregnancy to build rapport and provide psychosocial support. Discussing the client's level of family/social support or fear of social discrimination is appropriate because these factors may prevent the client from obtaining prenatal care. Pregnant adolescents are vulnerable to poverty, dangerous living conditions, exposure to teratogens (eg, tobacco, alcohol, illicit drugs), poor nutritional status, and physical or sexual abuse, which can cause adverse fetal/maternal outcomes. Therefore, discussing these topics openly as soon as possible is appropriate to prevent harm. Incorrect Answers: [A. Desire for adoption planning services] Discussing adoption planning and parenting is not necessary at this time but should be addressed later in collaboration with a social worker. [E. Plan for finishing high school] Young adolescents (ie, age <16) are less mature emotionally and developmentally and may resist planning for the future. Education planning may be approached during subsequent encounters, but it is not a priority for maternal and fetal health at this time. Educational objective:Pregnant adolescent clients are at an increased risk for complications during pregnancy. Factors such as emotional response to the pregnancy, family/social support, nutritional status, and substance abuse impact the pregnancy and should be discussed during an initial encounter to establish rapport and prevent harm.

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention? A. Client has not been taking prenatal vitamins B. Client is taking lisinopril to control hypertension C. Client reports a whitish vaginal discharge D. Client reports mild cramping pain in the lower abdomen

Correct Answer: B. Client is taking lisinopril to control hypertension Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril, lisinopril, ramipril) and angiotensin II receptor blockers (eg, losartan, valsartan, telmisartan) should be avoided in clients who are planning to become pregnant. These drugs are teratogenic, leading to fetal renal and cardiac abnormalities, and are contraindicated in all stages of pregnancy. Incorrect Answers: [A. Client has not been taking prenatal vitamins] Prenatal supplements, especially folic acid and iron, are recommended during pregnancy. Although important, this is not a priority over discontinuing ACE inhibitors. [C. Client reports a whitish vaginal discharge] Leukorrhea, a whitish vaginal discharge, is common during the prenatal period. The client should be instructed to call the health care provider if the discharge is accompanied by other signs or symptoms, such as a foul odor, redness, or itching. [D. Client reports mild cramping pain in the lower abdomen] As the uterus enlarges, cramping may occur in the lower abdomen and inguinal region. This common finding can be caused by stretching of the round ligaments, and is usually not concerning in the absence of vaginal bleeding. Educational objective:Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are teratogenic and need to be discontinued when planning pregnancy.

The nurse is caring for 4 hospitalized clients. Which client should the nurse see first? A. Client with hyperemesis gravidarum who is currently vomiting B. Client with molar pregnancy who has dark brown vaginal discharge C. Client with suspected ectopic pregnancy who has abdominal and shoulder pain D. Client with threatened miscarriage who says, "I am a Jehovah's Witness."

Correct Answer: C. Client with suspected ectopic pregnancy who has abdominal and shoulder pain An ectopic pregnancy occurs when a fertilized egg implants and begins to grow outside the uterine cavity, most often in the fallopian tubes. The fetus cannot survive; it will grow and cause a rupture of the fallopian tube if left untreated. Clients with an ectopic pregnancy report sudden-onset abdominal or pelvic pain. Shoulder pain (referred pain) is a classic sign of irritation of the diaphragm; it is usually due to intraabdominal bleeding and may indicate a ruptured ectopic pregnancy. This is a surgical emergency due to blood loss and requires priority hemodynamic support (eg, IV fluids, blood transfusion). Incorrect Answers: [A. Client with hyperemesis gravidarum who is currently vomiting] Clients with hyperemesis gravidarum have excess nausea and vomiting. The condition is usually not life-threatening. [B. Client with molar pregnancy who has dark brown vaginal discharge] In a molar pregnancy, fetal parts are replaced by edematous, cystic chorionic villi. There is no viable pregnancy. Clients report intermittent dark brown to bright red vaginal discharge that may contain grape-like vesicles. This is expected until the molar pregnancy is evacuated. This client should be taught not to become pregnant within one year of the molar pregnancy and to have frequent checks for cancer during this time. [D. Client with threatened miscarriage who says, "I am a Jehovah's Witness."] Jehovah's Witness clients do not allow blood transfusions due to religious beliefs. Clients with threatened miscarriage usually report spotting, but the cervix has not dilated. The pregnancy is intact, and there is no urgent need for blood transfusion. Educational objective:Ectopic pregnancy is a serious condition that results in loss of the fetus and could be life-threatening to the mother if not treated quickly. When a fertilized egg begins to grow outside the uterus (eg, in a fallopian tube), the risk of rupture increases. Rupture of the tube will result in significant blood loss and requires surgery and possible transfusion. Shoulder pain in clients with ectopic pregnancy indicates intraabdominal bleeding.

While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? A. First-trimester client who reports frequent nausea and vomiting B. Second-trimester client with dysuria and urinary frequency C. Second-trimester client with obesity who reports decrease in fetal movement D. Third-trimester client with right upper quadrant pain and nausea

Correct Answer: D. Third-trimester client with right upper quadrant pain and nausea Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present. Incorrect Answers: [A. First-trimester client who reports frequent nausea and vomiting] Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention. [B. Second-trimester client with dysuria and urinary frequency] Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should be evaluated but does not take priority over a client with symptoms of HELLP. [C. Second-trimester client with obesity who reports decrease in fetal movement] Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position, anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of decreased fetal movement; however, this is not the priority. Educational objective:HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise. Complications, including placental abruption, stroke, and death, may occur if HELLP syndrome is not treated immediately.

The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first? A. Alert the supervising registered nurse B. Check the client's blood pressure and pulse C. Listen to the fetal heart rate D. Turn the client to a lateral position

Correct Answer: D. Turn the client to a lateral position Supine hypotension occurs most commonly in the third trimester when the weight of the gravid uterus compresses the vena cava. This results in decreased venous return to the heart, reducing cardiac output and causing maternal hypotension and reflex tachycardia. Clients may experience dizziness and nausea; other signs may include pallor and cold, clammy skin. If a pregnant client becomes symptomatic (eg, dizzy, nauseated) while lying supine, immediate repositioning to the left side is necessary to relieve vena caval compression. Placing a wedge under the client's right hip while lying supine helps prevent supine hypotension. Incorrect Answer: [A. Alert the supervising registered nurse] The practical nurse should notify the supervising registered nurse after placing the client in a lateral position. [B. Check the client's blood pressure and pulse] Hypotension should resolve quickly after repositioning; therefore, the nurse should check the client's blood pressure and pulse soon after to ensure vital signs are stable. [C. Listen to the fetal heart rate] Decreased maternal cardiac output can result in impaired placental blood flow and fetal heart rate (FHR) abnormalities. Once the nurse tilts the client to a left lateral position, the nurse should verify that the FHR is normal. Educational objective:Supine hypotension occurs commonly in the third trimester when the gravid uterus compresses the vena cava, resulting in decreased venous return to the heart and maternal hypotension. If a pregnant client becomes symptomatic (eg, dizzy, nauseated) while lying supine, the nurse should immediately reposition the client to the left side.

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place.

Correct Answer: 1.2 mL The client is in active labor with an established contraction pattern and pain in the severe range. This is considered a safe time in labor to administer pain medication. The usual dose of nalbuphine hydrochloride is 10-20 mg, and the dose prescribed is within the normal dose range for labor. The nurse must convert the client's weight to kilograms (1 kg = 2.2 lb) and then determine the desired dose in milligrams. Finally, the nurse must calculate the dose to be administered in milliliters. Educational objective:The usual and safe dose of nalbuphine hydrochloride is 10-20 mg/70 kg of body weight given intramuscularly or by IV push. The nurse should convert weight to kilograms and then calculate the dose in milliliters based on the client's body weight and using the 2 formulas: Desired dose = Prescribed amount (mg/kg) x weight (kg)

The nurse preceptor should intervene if the graduate practical nurse performs which action when caring for a jaundiced newborn being treated with phototherapy? A. Allowing the parents to feed the newborn B. Applying a shirt while the newborn is exposed to phototherapy C. Assessing the temperature of the incubator while the newborn is inside D. Covering the newborn's eyes with protective shields

`Correct Answer: B. Applying a shirt while the newborn is exposed to phototherapy Phototherapy is the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool and urine. The newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is important as bilirubin products in the stool can cause loose stool with frequency and produce skin excoriation and breakdown. Incorrect Answers: [A. Allowing the parents to feed the newborn] Allowing parents to feed the newborn promotes bonding. The newborn should not be removed from the lights except during feedings for optimal effect of the phototherapy. Adequate hydration with human milk or infant formula (not water) is important as infants are prone to dehydration from phototherapy. [C. Assessing the temperature of the incubator while the newborn is inside] Temperature should be monitored closely, with the incubator placed on a low-heat setting. [D. Covering the newborn's eyes with protective shields] The newborn's eyes should be covered with patches or guards to prevent retinal damage or cataracts when under the phototherapy lights. Educational objective:The newborn should be fully exposed, except for a diaper, when placed under phototherapy lights. Lotions and ointments should not be applied as they can absorb heat and cause burns. Newborns should wear eye shields and be monitored for adequate hydration and urine output.

The nurse is performing postdelivery care of a newborn delivered at 35 weeks gestation. Which of the following actions by the nurse are appropriate? Select all that apply. A. Covers the scale with warmed blankets before weighing the newborn B. Encourages skin-to-skin contact between the stable newborn and mother C. Performs diaper changes underneath a radiant warmer D. Places the identification band on the newborn before beginning to dry off amniotic fluid E. Transfers the swaddled newborn to the neonatal intensive care unit in an open bassinet

Correct Answer: A, B, and C Preterm newborns are at high risk for cold stress due to immaturity of the thermoregulatory center in the brain, inadequate subcutaneous fat, and an inability to initiate shivering. These attributes make it difficult for the preterm newborn to maintain normal body temperature (axillary temperature of 97.7-99.5 F [36.5-37.5 C]). Covering the scale with warmed blankets protects against conductive heat loss, which may occur when the newborn's skin comes into contact with a cooler surface. Skin-to-skin contact with the parents for stable, preterm newborns promotes thermoregulation through conduction of body heat to the newborn. Radiant warmers and incubators provide heat through convection and are routinely used to help newborns regulate their core temperatures. Providing care underneath the radiant warmer protects newborns from convection heat loss by reducing exposure to the cooler ambient environment and air drafts Incorrect Answers: [D. Places the identification band on the newborn before beginning to dry off amniotic fluid] Drying the newborn completely of amniotic fluid immediately following birth protects the newborn from heat loss by evaporation and should occur prior to or simultaneously with other interventions. [E. Transfers the swaddled newborn to the neonatal intensive care unit in an open bassinet] The preterm newborn should be transferred from the birthing room to the intensive care unit via a prewarmed incubator to prevent heat loss by convection. Educational objective:Preterm newborns are at increased risk for cold stress and heat loss. The nurse can help prevent cold stress by covering cool surfaces with warm blankets, completely drying the newborn after birth, providing care in the radiant warmer, transferring the newborn in a prewarmed incubator, and encouraging skin-to-skin contact.

A client comes to the clinic indicating that a home pregnancy test was positive. The client's last menstrual period was September 7. Today is December 7. Which are true statements for this client? Select all that apply. A. According to Naegele's rule, the expected date of delivery is June 14 B. Detection of the fetal heart rate via Doppler is possible C. Fundal height should be 24 cm above the symphysis pubis D. The client should be feeling fetal movement E. Urinary frequency is a common symptom

Correct Answer: A, B, and E Naegele's rule, which is the last menstrual period minus 3 months plus 7 days, can be used to calculate a client's expected date of delivery. The accuracy of this method may be influenced by the regularity and length of the client's menstrual cycle. September 7 minus 3 months is June 7, plus 7 days is June 14. Detection of a fetal heart rate is possible using a Doppler by 10-12 weeks gestation. Urinary frequency, a presumptive sign of pregnancy common in the first trimester, occurs primarily due to hormonal changes and anatomical changes in the renal system. However, clients also reporting dysuria, fever/chills, or back pain should be evaluated for a urinary tract infection. Incorrect Answers: [C. Fundal height should be 24 cm above the symphysis pubis] Uterine growth is assessed by measuring fundal height using a measuring tape. After 20 weeks gestation, the fundal height measurement in centimeters should correlate closely with the number of weeks pregnant (eg, 24 cm = 24 weeks). The client should empty the bladder before having fundal height measured, as a full bladder can displace the uterus and affect measurement accuracy. [D. The client should be feeling fetal movement] Quickening, the awareness of fetal movements, occurs around 18-20 weeks gestation in primigravidas and at 14-16 weeks in multigravidas. Educational objective:Naegele's rule for estimating date of delivery is the last menstrual period minus 3 months plus 7 days. Fetal heart rate is detectable by Doppler at 10-12 weeks gestation. Urinary frequency is a presumptive sign of pregnancy in the first trimester.

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? A. "Are you having any pain in your lower back or flank area?" B. "Do you wipe from front to back after urinating?" C. "Have you found that you urinate more frequently since becoming pregnant?" D. "Have you had a urinary tract infection in the past?"

Correct Answer: A. "Are you having any pain in your lower back or flank area?" Urinary tract infections (UTIs) are common during pregnancy due to physiologic renal system changes (eg, ureter dilation, urine stasis). Most UTIs are confined to the lower urinary tract (ie, cystitis, or bladder infection). Symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and a sensation of bladder fullness. Diagnostic testing includes urinalysis and urine culture. Oral antibiotics are required to appropriately treat cystitis. If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis. During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm labor. Therefore, priority assessment is to rule out indicators of pyelonephritis (eg, flank pain, fever) in clients who report UTI symptoms to ensure appropriate diagnosis and treatment. Incorrect Answers: [B. "Do you wipe from front to back after urinating?"] Wiping front to back after urination may help prevent Escherichia coli (a common UTI pathogen found in stool) from contaminating the urethra. Reviewing toileting hygiene is important but does not help assess current symptoms. [C. "Have you found that you urinate more frequently since becoming pregnant?"] Urinary frequency and nocturia are common during pregnancy. However, the nurse should not focus on the normalcy of urinary frequency since the client has reported additional symptoms (eg, dysuria). [D. "Have you had a urinary tract infection in the past?"] Pregnancy predisposes clients to UTIs. Furthermore, assessing for history of UTI does little to address the client's current symptoms. Educational objective: Urinary tract infections are common during pregnancy. If the client reports signs and symptoms of cystitis, the nurse's priority is to rule out ascending infection (ie, pyelonephritis), which would require hospitalization and IV antibiotics.

The nurse is reinforcing education to a prenatal client about the 1-hour glucose challenge test that will be performed at the next visit. Which client statement indicates a need for further education? A. "Fasting is required before the 1-hour glucose challenge test." B. "One blood sample is obtained at the end of the test." C. "The test includes drinking a 50-g glucose solution." D. "The test's purpose is to screen for gestational diabetes, not diagnose it."

Correct Answer: A. "Fasting is required before the 1-hour glucose challenge test." Gestational diabetes mellitus (GDM) is diagnosed in clients with impaired blood glucose (BG) regulation due to physiologic pregnancy changes (eg, rising BG levels, insulin resistance). GDM screening occurs at 24-28 weeks gestation. If GDM is diagnosed, management includes nutritional counseling and, if needed, pharmacologic therapy. Two-step GDM testing begins with a screening test: the 1-hour glucose challenge test (GCT). The 1-hour GCT can be performed any time of day and does not require fasting. If the client's serum BG is <140 mg/dL, GDM is unlikely, and the client requires no further testing. If serum BG is ≥140 mg/dL, the client requires a 2- or 3-hour glucose tolerance test (GTT) to diagnose GDM. Incorrect Answers: [B. "One blood sample is obtained at the end of the test."] For the 1-hour GCT, the nurse draws one blood sample an hour after ingestion of a 50-g glucose solution (eg, glucola). In contrast, a 2- or 3-hour GTT requires the nurse to obtain fasting and hourly blood samples. [C. "The test includes drinking a 50-g glucose solution."] For the 1-hour GCT, the nurse draws one blood sample an hour after ingestion of a 50-g glucose solution (eg, glucola). In contrast, a 2- or 3-hour GTT requires the nurse to obtain fasting and hourly blood samples. [D. "The test's purpose is to screen for gestational diabetes, not diagnose it."] The 1-hour GCT is a screening test only. Educational objective:The 1-hour glucose challenge test (GCT) screens pregnant clients for gestational diabetes mellitus. Screening occurs at 24-28 weeks gestation. The client ingests a 50-g glucose solution, and the nurse draws one blood sample an hour later. The 1-hour GCT can be performed any time of day and does not require fasting.

Of the abdominal lines shown in the exhibit, where would the nurse expect the fundal height of a 20-week gestation client to be felt? A. A B. B C. C D. D

Correct Answer: C. C The client's fundal height is measured, in centimeters, during pregnancy to assess fetal and uterine growth. This should be done at each prenatal visit. The fundus can be palpated above the symphysis pubis at 12-14 weeks gestation and correlates approximately with gestational age until 36 weeks gestation. The fundal height should be at the level of the client's umbilicus at 20-22 weeks gestation. Incorrect Answers: [A. A] The fundus should be at this level at 36 weeks gestation. [B. B] The fundus should be at this level at 28 weeks gestation. [D. D] The fundus should be at this level at 12 weeks gestation. Educational objective:The fundus should be palpated and the height measured at each prenatal visit. The fundus should be at the level of the client's umbilicus at 20-22 weeks gestation.

A nurse is caring for a postpartum client who has breast engorgement following breastfeeding. Which instructions should the nurse reinforce regarding relief of breast engorgement? A. Allow newborn to nurse for at least 10-15 minutes on each breast B. Apply ice packs to breasts for 15-20 minutes before breastfeeding C. Decrease the frequency of breastfeeding D. Manually express or pump breast milk several times each day

Correct Answer: A. Allow newborn to nurse for at least 10-15 minutes on each breast Breast engorgement is often painful, and the following treatments are recommended in a client who is breastfeeding: 1. Continue breastfeeding - Frequent feedings with complete emptying of each breast is the best treatment for breast engorgement. Newborns should nurse for at least 10-15 minutes on each breast to ensure complete emptying. 2. Do not pump breasts between feedings - Pumping between feedings will increase breast milk production and worsen breast engorgement. 3. Apply a warm/cold compress - Warm compresses can be used to soften the breast and nipple before breastfeeding, and cold compresses can be used to minimize swelling afterward. 4. Take warm showers - Allowing warm water to trickle over breasts in the shower a few times a day minimizes discomfort and reduces pressure by allowing a small amount of milk to be released. 5. Use anti-inflammatory analgesics - An anti-inflammatory drug, such as ibuprofen, is recommended for pain associated with breast engorgement. Incorrect Answers: [B. Apply ice packs to breasts for 15-20 minutes before breastfeeding] Although application of ice minimizes swelling, warm compresses are recommended before attempting to breastfeed. [C. Decrease the frequency of breastfeeding] Breastfeeding should be continued during treatment of breast engorgement. [D. Manually express or pump breast milk several times each day] Manually expressing or pumping breast milk is indicated only if the newborn misses a feeding. Breastfeeding is a supply and demand process; manually expressing breast milk and pumping will increase milk production. Educational objective:For breast engorgement in a client who is breastfeeding, treatments that the nurse should recommend include frequent breastfeeding with complete emptying of the breasts, avoidance of pumping and expressing breast milk between feedings, and managing pain with warm/cold compresses and anti-inflammatory analgesics.

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? A. Applying counterpressure to the client's sacrum during contractions B. Encouraging the client to remain in bed during early labor C. Positioning the client on the left side with pillows for support D. Requesting that the nurse anesthetist administer epidural anesthesia

Correct Answer: A. Applying counterpressure to the client's sacrum during contractions Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis). The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, heel of the hand, or other firm object (eg, tennis ball, back massager). Incorrect Answers: [B. Encouraging the client to remain in bed during early labor] Clients should be encouraged to change positions frequently (every 30-60 minutes) during labor to promote fetal rotation/descent and increase maternal comfort. Remaining in bed during early labor increases the risk for persistent fetal malposition and slows labor progression. [C. Positioning the client on the left side with pillows for support] Left lateral positioning is better for uteroplacental blood flow and fetal oxygenation than supine positioning when the client is resting in bed. However, it may not alleviate the client's back pain. [D. Requesting that the nurse anesthetist administer epidural anesthesia] Although epidural anesthesia can provide effective pain relief, it can limit client mobility and contribute to persistent fetal malposition. This client is also still in early labor and has not requested an epidural at this time. Educational objective:Fetal occiput posterior position may cause intense back pain during labor. Client comfort can be increased by applying counterpressure to the sacrum during contractions.

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? A. Bishop score of 10 B. Firm and posterior cervix C. History of precipitous labor D. Reactive nonstress test

Correct Answer: A. Bishop score of 10 The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥6-8 usually indicates that induction will be successful. Incorrect Answers: [B. Firm and posterior cervix] A cervix that is firm and posterior is associated with a low Bishop score, which reflects a low likelihood of successful labor induction. [C. History of precipitous labor] A history of precipitous labor (<3 hours from onset of contractions to birth) may indicate that the client will again experience precipitous labor once labor is established. However, such a history is not an independent predictor of successful induction. [D. Reactive nonstress test] A reactive nonstress test indicates that the fetus is well oxygenated and establishes fetal well-being. It does not provide information about the likely success or failure of labor induction. Educational objective:The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. A score ≥6-8 in nulliparous women is associated with successful induction and subsequent vaginal birth.

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? A. Cessation of contractions and maternal tachycardia B. Fetal tachycardia with moderate variability C. Increased anxiety and discomfort with contractions D. Painful, strong contractions every 3-4 minutes

Correct Answer: A. Cessation of contractions and maternal tachycardia Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions. Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. Incorrect Answers: [B. Fetal tachycardia with moderate variability] Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. However, moderate variability is a reassuring sign predictive of adequate fetal oxygenation. [C. Increased anxiety and discomfort with contractions] Contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture. [D. Painful, strong contractions every 3-4 minutes] The nurse should be hypervigilant for tachysystole, which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern. Educational objective:Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

During an initial prenatal visit, the practical nurse is reviewing the history of a client at 10 weeks gestation. Which finding is a priority to report to the registered nurse? A. Client cares for a pet dog and a few outdoor cats B. Client has gained 4 lb (1.8 kg) during the pregnancy so far C. Client reports a nonodorous, milky white vaginal discharge D. Client swims in a pool for exercise three times per week

Correct Answer: A. Client cares for a pet dog and a few outdoor cats Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii and may be acquired from exposure to infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis can transfer the infection to the fetus, potentially causing serious fetal harm (eg, stillbirth, malformations, blindness, mental disability). Pregnant clients who may be exposed to infected cats (eg, cats that live outdoors or eat raw meat) should be advised to avoid contact with cat feces (eg, litter box) and wash hands thoroughly after contact to decrease exposure risk. Incorrect Answers: [B. Client has gained 4 lb (1.8 kg) during the pregnancy so far] Weight gain recommendations vary by prepregnancy BMI. Gaining 1.1-4.4 lb (0.5-2.0 kg) during the first trimester is normal and expected. [C. Client reports a nonodorous, milky white vaginal discharge] Leukorrhea is a thin, milky white vaginal discharge that is normal during pregnancy and caused by increased levels of estrogen. If the vaginal discharge changes color, becomes malodorous, or causes itching/burning, further investigation is needed. [D. Client swims in a pool for exercise three times per week] Exercise, particularly low-impact activities such as walking, swimming, and yoga, is recommended during pregnancy. Contact sports or activities with a risk for falls (eg, soccer, downhill skiing) should be avoided to prevent abdominal injuries. Educational objective:Toxoplasmosis is a parasitic infection acquired by exposure to infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis may transfer the infection to the fetus and potentially cause serious fetal harm.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? A. Contraction duration of 95 seconds B. Contraction frequency of every 3 minutes C. Contraction intensity of 45 mm Hg D. Uterine resting tone of 10 mm Hg

Correct Answer: A. Contraction duration of 95 seconds Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity. Incorrect Answers: [B. Contraction frequency of every 3 minutes] Uterine frequency should be 2-5 contractions every 10 minutes. If contractions occur less than 2 minutes apart, fetal distress can occur as a result of uteroplacental insufficiency. [C. Contraction intensity of 45 mm Hg] In the first stage of labor, the intensity of uterine contractions should be 25-50 mm Hg. Intrauterine pressure of more than 80 mm Hg is a sign of hypertonicity of the uterus [D. Uterine resting tone of 10 mm Hg] Uterine resting tone of 20 mm Hg or less is considered acceptable. Uterine resting tone allows blood flow to the placenta and therefore the fetus, ensuring a well-oxygenated fetus. Educational objective: Uterine contractions during labor dilate and efface the cervix and cause descent of the fetus. The contraction duration should not exceed 90 seconds or occur less than 2 minutes apart. Excess resting tone, contraction duration, and frequency result in uteroplacental insufficiency.

The practical nurse (PN) is assisting the registered nurse (RN) to care for a 6-hour-old term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL (2.5 mmol/L). The newborn is asymptomatic. Which intervention should the PN anticipate implementing first? A. Feed the newborn B. Notify the health care provider C. Place the newborn under a radiant warmer D. Prepare to administer IV glucose

Correct Answer: A. Feed the newborn Poorly controlled diabetes mellitus during pregnancy exposes the fetus to high blood glucose (BG) levels. This results in fetal hyperglycemia, which causes insulin hypersecretion by the fetus and promotes abnormal growth and storage of fat (macrosomia). Immediately after birth, transient hyperinsulinemia and a sudden cessation of the maternal glucose supply puts the newborn at risk for hypoglycemia. Although no standard definition for newborn hypoglycemia currently exists, a normal range for serum BG in a newborn who is <24 hours old is 40-60 mg/dL (2.2-3.3 mmol/L) and a low BG is (<40-45 mg/dL [2.2-2.5 mmol/L]). If a newborn has a low BG and is asymptomatic, then immediate feeding with formula or breast milk is indicated to increase BG and prevent further hypoglycemia Incorrect Answers: [B. Notify the health care provider ] If the newborn is symptomatic or BG levels remain <40-45 mg/dL (2.2-2.5 mmol/L) after feeding, the nurse should notify the health care provider and prepare to administer IV glucose. [C. Place the newborn under a radiant warmer] Although cold stress may cause hypoglycemia, feeding the newborn and keeping the newborn warm via skin-to-skin contact is priority. [D. Prepare to administer IV glucose] Hypoglycemic newborns who are symptomatic (eg, poor feeding, jittery, irritable) or those who cannot increase their BG through feeding require IV glucose administration. Educational objective:Hypoglycemia occurs commonly in newborns of mothers with diabetes due to elevated insulin levels and consumption of stored glucose. Common signs include jitteriness or tremors. Asymptomatic newborns with a low blood glucose (<40-45 mg/dL [2.2-2.5 mmol/L]) should be fed breast milk or formula immediately.

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? A. Hemoglobin and hematocrit levels B. Human chorionic gonadotropin level C. Serum folate level D. White blood cell count

Correct Answer: A. Hemoglobin and hematocrit levels Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. Incorrect Answers: [B. Human chorionic gonadotropin level] Human chorionic gonadotropin is the hormone detected in a urine or serum pregnancy test to determine if a client is pregnant. It is not affected by iron deficiency anemia or pica. [C. Serum folate level] Increased folic acid consumption is necessary during pregnancy to reduce the risk for neural tube defects in the developing fetus. However, folate levels are not related to pica. [D. White blood cell count] A white blood cell count should be assessed when a client is suspected of having an infection. There is no indication that this client has an infection. Educational objective:Pica is the constant craving for and consumption of nonfood and/or nonnutritive food substances that may occur in pregnancy. It may be accompanied by iron deficiency anemia. Hemoglobin and hematocrit levels are useful in these clients to screen for anemia.

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage? A. Infant birth weight of 9 lb 2 oz (4139 g) B. Labor and birth without pain medication C. Labor that lasted 8 hours D. Third stage of labor lasting 20 minutes

Correct Answer: A. Infant birth weight of 9 lb 2 oz (4139 g) Postpartum hemorrhage (PPH) is usually defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth. Uterine atony, characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early PPH (occurring ≤24 hours after birth). Delayed PPH (>24 hours after birth) usually results from retained placental fragments associated with a long third stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes). Risk factors for PPH include: · History of PPH in prior pregnancy · Uterine distension due to: o Multiple gestation o Polyhydramnios (ie, excessive amniotic fluid) o Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option 1) · Uterine fatigue (labor lasting >24 hours) · High parity · Use of certain medications: o Magnesium sulfate o Prolonged use of oxytocin during labor o Inhaled anesthesia (ie, general anesthesia) Incorrect Answers [B. Labor and birth without pain medication] Natural, unmedicated labor and birth reduces the chance of PPH. [C. Labor that lasted 8 hours] Labor lasting <24 hours does not increase the risk for PPH. [D. Third stage of labor lasting 20 minutes] A third stage of labor lasting <30 minutes does not increase the risk for PPH. Educational objective:Postpartum hemorrhage is defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth. Uterine atony (ie, "boggy" uterus) is the most common cause of early postpartum hemorrhage (occurring ≤24 hours after birth). Risk factors include uterine distension, uterine fatigue, high parity, and certain medications.

The nurse is caring for a postpartum couplet and notices that the newborn is cyanotic and apneic, with a heart rate of 70/min. The nurse calls for help and begins resuscitation. Which position is appropriate for ventilating the newborn? A. Normal with small towel placed beneath shoulders B. Slightly flexed C. Hyperextended D. Flexsion with small towel placed beneath shoulders

Correct Answer: A. Normal with small towel placed beneath shoulders Before newborn resuscitation, the nurse should place the infant on the back with the neck slightly extended to promote adequate ventilation. Very slight neck extension, otherwise known as the neutral or sniffing position, ensures a patent airway. The nurse may need to place a blanket or towel roll under the newborn's shoulders to elevate the chest ¾-1 inch (2-2.5 cm) above the mattress. This technique may be particularly useful for maintaining the sniffing position during ventilation if the newborn has a large occiput from molding or edema (eg, caput succedaneum) Incorrect Answers: [B. Slightly flexed] The newborn's neck is not well extended and slightly flexed, which can decrease air entry. [C. Hyperextended] The newborn's neck is hyperextended, which can decrease air entry. [D. Flexsion with small towel placed beneath shoulders] A blanket or towel roll under the newborn's occiput results in significant neck flexion and decreases air entry. Educational objective:Before newborn resuscitation, the nurse should position the newborn with the neck slightly extended (ie, sniffing position) to allow proper air entry into the lungs during ventilation. In addition, a blanket or towel roll placed under the newborn's shoulders may facilitate positioning.

The nurse is reinforcing education to a pregnant client who is HIV-positive. Which information is appropriate for the nurse to include? A. Prescribed antiretroviral therapy should be continued during pregnancy B. Tetanus-diphtheria-acellular pertussis vaccine should be avoided until after birth C. The infant should be exclusively breastfed for 6 months to receive maternal antibodies D. The infant will not require treatment for HIV after birth

Correct Answer: A. Prescribed antiretroviral therapy should be continued during pregnancy Perinatal transmission of HIV infection from mother to baby can occur anytime during the antepartum, intrapartum, or postpartum periods. Maternal antiretroviral therapy (ART) during pregnancy is imperative for decreasing viral load (amount of virus detectable in maternal serum) and decreasing risk of transmission to the fetus. Incorrect Answer: [B. Tetanus-diphtheria-acellular pertussis vaccine should be avoided until after birth] Pregnant clients who are HIV-positive are immunocompromised and at increased risk for other infections. They should receive all recommended, inactivated vaccines for the general pregnant population, such as tetanus-diphtheria-acellular pertussis and IM influenza. Live attenuated vaccines (eg, measles, mumps, and rubella) are contraindicated during pregnancy. [C. The infant should be exclusively breastfed for 6 months to receive maternal antibodies] HIV can be transmitted to the newborn via breast milk. Breastfeeding is contraindicated for HIV-positive mothers in developed countries where safe alternatives (eg, commercial formula) are available. [D. The infant will not require treatment for HIV after birth] In addition to routine newborn care, infants born to HIV-positive clients should receive ART at birth and for at least 4-6 weeks after birth to reduce the chance of developing HIV infection. Infants are tested for HIV infection at birth and again at age 1 and 4 months. Identification of HIV-negative status requires 2 consecutive negative results at age ≥1 month and ≥4 months. Educational objective:Transmission of HIV infection from mother to infant can occur during the antepartum, intrapartum, or postpartum periods. Maternal antiretroviral therapy (ART) during pregnancy is imperative for decreasing the risk of perinatal transmission. Pregnant clients who are HIV-positive should receive recommended, inactivated vaccines (eg, tetanus-diphtheria-acellular pertussis). Newborns of HIV-positive clients should not be breastfed and should receive 4-6 weeks of ART after birth.

The nurse is collecting data on a client who has arrived at the clinic for pregnancy confirmation and prenatal evaluation. Which of the following findings indicate diagnostic evidence (positive signs) of pregnancy? Select all that apply. A. Cervical softening upon examination B. Fetal heart tones detected by Doppler device C. Positive serum human chorionic gonadotropin test D. Report of fetal movement felt by client E. Visualization of fetus via ultrasound

Correct Answer: B and E Positive (diagnostic) signs of pregnancy represent conclusive evidence of pregnancy that cannot be attributed to any other etiology. These signs include a discernible fetal heartbeat heard by Doppler device, ultrasound visualization of the fetus, and fetal movement palpated or observed by the health care provider (HCP). Presumptive (subjective) signs of pregnancy (eg, breast tenderness, nausea, amenorrhea) are self-reported by the client. These signs may be related to other medical conditions and therefore cannot be considered diagnostic of pregnancy. Probable (objective) signs of pregnancy (eg, cervical changes, positive pregnancy test) are observed by the HCP during assessment and examination. Compared with subjective signs, objective signs may be more indicative of pregnancy but may still have alternate causes. Incorrect Answer: [A. Cervical softening upon examination] Cervical softening is an objective sign of pregnancy as it may also be caused by other conditions that result in pelvic congestion (eg, use of hormonal contraceptives, uterine tumors). [C. Positive serum human chorionic gonadotropin test] A positive serum human chorionic gonadotropin test is considered an objective sign of pregnancy because it is also an indicator of gestational trophoblastic disease (eg, molar pregnancy). Ultrasound confirmation is needed to definitively confirm the pregnancy. [D. Report of fetal movement felt by client] The client's perception of fetal movement, known as quickening, is a presumptive sign of pregnancy. Educational objective:Positive signs of pregnancy represent conclusive evidence of pregnancy. These signs include a distinguishable fetal heartbeat heard by Doppler device, fetal movement palpated or observed by the health care provider, and ultrasound visualization of the fetus.

The nurse assists with data collection during a routine prenatal visit for a client at 36 weeks gestation. Which statement by the client is most concerning to the nurse? A. "I am not sleeping as well due to cramps in my calves at night." B. "I have noticed fewer kicking movements as the baby grows bigger." C. "Over the last few weeks, I have not been able to wear any of my shoes." D. "Sometimes I feel short of breath after walking up a flight of stairs."

Correct Answer: B. "I have noticed fewer kicking movements as the baby grows bigger." Fetal movement is a sign of fetal health and indicates an intact fetal central nervous system. Fetal movement may occur numerous times per hour during the last trimester of pregnancy, although the client may not perceive every movement. Multiple factors (eg, maternal substance abuse, medications, fasting, fetal sleep) can affect fetal movement. However, fetal movements should not decrease as the fetus increases in size. Decreased fetal movement is a potential warning sign of fetal compromise (ie, impaired oxygenation), which may precede fetal death. The nurse should prioritize client reports of decreased fetal movement in order to evaluate fetal well-being (eg, nonstress test). Incorrect Answers: [A. "I am not sleeping as well due to cramps in my calves at night."] Leg cramps commonly occur in the third trimester, especially at night, due to the weight of the gravid uterus applying pressure to nerves affecting the calf muscles. Home interventions include stretching the legs, massaging the calves, and increasing fluid intake. [C. "Over the last few weeks, I have not been able to wear any of my shoes."] Dependent edema in the lower extremities is common in the third trimester due to decreased venous return (ie, gravid uterus pressure on the vena cava), especially with prolonged sitting/standing. This is not a priority over decreased fetal movement. [D. "Sometimes I feel short of breath after walking up a flight of stairs."] As the uterus rises in the third trimester, the diaphragm is prevented from allowing full lung expansion, causing dyspnea, especially with exertion. Educational objective:Fetal movement is a sign of fetal health and represents an intact fetal central nervous system. The nurse should reinforce education to clients about fetal movements (ie, movements should not decrease in the late third trimester) and prioritize client reports of decreased fetal movement.

The nurse is reinforcing teaching to a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement made by the client indicates an appropriate understanding about weight gain? A. "I should gain 10 pounds during the first trimester." B. "I should gain about 30 pounds during the entire pregnancy." C. "I should gain no more than half a pound per week during the third trimester." D. "If I gain no more than 20 pounds during pregnancy, it will be easier to lose weight postpartum."

Correct Answer: B. "I should gain about 30 pounds during the entire pregnancy." Appropriate weight gain during pregnancy decreases risks to the client and fetus. Optimal weight gain is determined by prepregnancy BMI. Underweight clients need to gain more weight (1 lb [0.5 kg] per week) during the second and third trimesters of pregnancy than obese clients (0.5 lb [0.2 kg] per week). However, weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI. With a prepregnancy BMI of 21 kg/m2, this client has an appropriate weight and should gain 25-35 lb (11.3-15.9 kg) over the course of the pregnancy. Incorrect Answers: [A. "I should gain 10 pounds during the first trimester."] Weight gain during the first trimester should be approximately 1.1-4.4 lb (0.5-2.0 kg). A 10-lb (4.5-kg) weight gain during the first 3 months of pregnancy would be excessive for any client. [C. "I should gain no more than half a pound per week during the third trimester."] A client of appropriate weight should gain approximately 1 lb (0.5 kg) per week during the second and third trimesters of pregnancy. A weight gain of only 0.5 lb (0.2 kg) per week is recommended for obese clients. [D. "If I gain no more than 20 pounds during pregnancy, it will be easier to lose weight postpartum."] A weight gain of <20 lb (9.1 kg) during pregnancy is inadequate for a client of appropriate weight. Restricting weight gain increases the risk of low fetal birth weight (<5.5 lb [2500 g]) and preterm birth. Educational objective:Appropriate weight gain during pregnancy decreases risks to the client and fetus. Weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI. The optimal total weight gain during pregnancy is determined by the client's prepregnancy BMI.

The nurse is reinforcing instructions to a parent about how to care for a newly circumcised newborn. Which statement by the parent indicates a need for further teaching? A. "Discharge and odor indicate infection of the circumcision site." B. "I will clean the area with alcohol-based wipes or soap water." C. "Infant crying during petrolatum gauze changes is expected." D. "The diaper should be changed at least every 4 hours."

Correct Answer: B. "I will clean the area with alcohol-based wipes or soap water." Complications of circumcision include hemorrhage, infection, and voiding difficulty. The area should be cleaned with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged alcohol-based wipes delay healing, cause discomfort, and should be avoided until the circumcision scar is healed (usually 5-6 days). Incorrect Answers: [A. "Discharge and odor indicate infection of the circumcision site."] Immediately after the procedure, the glans penis should appear dark red and, after 24 hours, will be covered with a yellow exudate that will persist for 2-3 days. Parents should not try to wipe or forcefully remove the exudate as this is part of the normal healing process. However, redness, swelling, odor, and discharge indicate infection. [C. "Infant crying during petrolatum gauze changes is expected."] Crying is expected during diaper and petroleum (Vaseline) gauze changes. Parents are often anxious and concerned about inflicting pain on their newborn. They should be informed that the discomfort is only brief and be encouraged to provide extra comfort measures (holding, feeding, nonnutritive suckling) after diaper changes. [D. "The diaper should be changed at least every 4 hours."] Diapers should be changed when soiled or at least every 4 hours to keep the area clean and assess for evidence of infection or bleeding. Petroleum gauze or ointment should be applied at every diaper change (unless Plastibell is used) to prevent sticking. The diaper should be secured loosely to minimize pressure against the circumcision site. Educational objective:In a recently circumcised newborn, parents should be taught to use only warm water for cleaning and avoid soap and alcohol-based wipes. After 24 hours, a yellow exudate forms as part of the normal healing process; it should not be removed. Pain is expected, and parents can provide additional comfort measures after diaper changes to minimize discomfort.

The practical nurse is collecting data on several clients in the antepartum unit. Which client should the practical nurse report to the registered nurse for further assessment? A. 24 weeks gestation, 1-hour glucose screen is 120 mg/dL B. 25 weeks gestation, hemoglobin is 9 g/dL C. 30 weeks gestation, nonstress test is reactive D. 36 weeks gestation, white blood cell count is 13,000/mm^3

Correct Answer: B. 25 weeks gestation, hemoglobin is 9 g/dL Iron deficiency anemia is a common complication during pregnancy. It is related to low iron stores and diets low in iron. During pregnancy, clients are diagnosed with iron deficiency anemia when their hemoglobin level is <11 g/dL in the first and third trimesters and <10.5 g/dL in the second trimester. A client with a hemoglobin level of 9 g/dL should be evaluated for additional signs of iron deficiency anemia (eg, fatigue, dizziness, tachycardia, tachypnea). Treatment involves increasing dietary iron and folate, along with iron supplementation (usually 325 mg ferrous sulfate tid). Incorrect Answer: [A. 24 weeks gestation, 1-hour glucose screen is 120 mg/dL] A 1-hour glucose screen, performed between 24 and 28 weeks gestation to screen for gestational diabetes, is considered abnormal if the result is ≥140 mg/dL. [C. 30 weeks gestation, nonstress test is reactive] A nonstress test (NST) evaluates fetal status by monitoring the fetal heart rate (FHR) with an external monitor. After 20 minutes, if there are ≥2 FHR accelerations of 15 beats above baseline lasting at least 15 seconds, the NST is considered reactive, indicating fetal well-being. [D. 36 weeks gestation, white blood cell count is 13,000/mm^3] During pregnancy, the white blood cell (WBC) level increases to support the immune system; WBC levels can reach 16,000/mm^3 during pregnancy (non-pregnancy normal: 4,000-11,000/mm^3). Educational objective:Clients are diagnosed with iron deficiency anemia when hemoglobin is <11 g/dL in the first and third trimesters and <10.5 g/dL in the second trimester.

The initial prenatal laboratory screening results of a client at 12 weeks gestation indicate a rubella titer status of nonimmune. What will the nurse anticipate as the plan of care for this client? A. Administer measles-mumps-rubella (MMR) vaccine now B. Administer MMR vaccine immediately postpartum C. Administer MMR vaccine in the third trimester D. An MMR vaccine is not indicated for this client

Correct Answer: B. Administer MMR vaccine immediately postpartum In a pregnant client, a serum sample is collected at the first prenatal visit to determine immunity to the rubella virus. A positive immune response indicates immunity to the rubella virus, attributed to either past infection or vaccination. A negative, or nonimmune, response indicates that the client is susceptible to rubella disease and requires vaccination. An equivocal response indicates partial immunity to rubella and is treated clinically the same as nonimmune status. Measles-mumps-rubella (MMR) is a live attenuated vaccine. Live vaccines are contraindicated in pregnancy due to the theoretical risk of contracting the disease from the vaccine. Maternal rubella infection can be teratogenic for the fetus. The fetal effects of congenital rubella syndrome include congenital cataracts, deafness, heart defects (patent ductus arteriosus), and cerebral palsy. The best time to administer an MMR vaccine to a nonimmune client is in the postpartum period just prior to discharge. The MMR vaccine can safely be administered to breastfeeding clients. Incorrect Answer: [A. Administer measles-mumps-rubella (MMR) vaccine now] MMR vaccine is contraindicated in pregnancy. Also, pregnancy should be avoided for at least 1-3 months after the immunization is given. [C. Administer MMR vaccine in the third trimester] MMR vaccine is contraindicated in pregnancy. Also, pregnancy should be avoided for at least 1-3 months after the immunization is given. [D. An MMR vaccine is not indicated for this client] This client is rubella nonimmune and is susceptible to rubella if exposed. The vaccine should be offered in the postpartum period. Educational objective:The measles-mumps-rubella vaccine is a live attenuated vaccine and is contraindicated in pregnancy due to the risk of teratogenic effects to the fetus. Clients who are nonimmune to rubella should receive the vaccine in the postpartum period. Pregnancy should be avoided for at least 1-3 months after immunization.

A pregnant client comes to the labor and delivery unit stating, "My water just broke at home." On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? A. Apply suprapubic pressure B. Assist the client to the knee-chest position C. Perform Leopold maneuvers D. Perform the McRoberts maneuver

Correct Answer: B. Assist the client to the knee-chest position Umbilical cord prolapse occurs when the umbilical cord slips below the presenting fetal part and causes cord compression and impaired fetal oxygenation. A loop of cord may be palpated during vaginal examination or visualized protruding from the vagina. An emergency cesarean birth is usually required unless vaginal birth is imminent and considered safe by the health care provider (HCP). Positioning the client on the hands and knees with the buttocks elevated above the head (knee-chest position) or in the Trendelenburg position relieves pressure on the compressed cord. The nurse may also use a sterile, gloved hand to lift the presenting part off the cord. Other actions include administration of oxygen and IV fluids. Incorrect Answers: [A. Apply suprapubic pressure] Suprapubic pressure helps dislodge an impacted anterior shoulder from under the client's pubic bone in the event of shoulder dystocia but does not relieve pressure off a prolapsed umbilical cord. [C. Perform Leopold maneuvers] Leopold maneuvers are used as a systematic approach to palpating the pregnant abdomen to identify fetal presentation. They are not used as an emergency intervention for umbilical cord prolapse. [D. Perform the McRoberts maneuver] The McRoberts maneuver consists of sharply flexing the thigh onto the maternal abdomen to straighten the sacrum. It is used for shoulder dystocia but does not take pressure off a prolapsed umbilical cord. Educational objective:A client with a prolapsed umbilical cord should be placed in the knee-chest or Trendelenburg position to relieve pressure on the cord until emergency birth is possible.

The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer? Vital Signs Temperature: 100.9 F (38.3 C) Blood Pressure: 125/75 mm Hg Heart Rate: 109/min Respirations: 15/min SPO2: 100% 0800: Fundus +2 above umbilicus with moderate tenderness to palpation. Small to moderate amount of foul-smelling lochia rubra noted with no clots. Perineal care provided. _________________, RN A. Acetaminophen PO PRN for fever B. Clindamycin IV every 8 hours C. Lactated Ringer IV bolus once D. Methylergonovine PO every 4 hours

Correct Answer: B. Clindamycin IV every 8 hours Postpartum endometritis occurs when the endometrium (uterine lining) becomes infected after birth, often beginning at the placental site. Endometritis is characterized by uterine tenderness and subinvolution, foul-smelling or purulent lochia, fever, tachycardia, and chills. Cesarean birth is a primary risk factor, particularly if performed emergently or after prolonged labor. The infection is usually polymicrobial and requires treatment with broad-spectrum antibiotics (eg, IV clindamycin plus IV gentamicin). Antibiotic administration is a priority because it treats the primary cause of endometritis and prevents complications related to the spread of infection (eg, abscess, peritonitis) Antibiotics are required until approximately 24 hours after symptoms resolve. Incorrect Answers: [A. Acetaminophen PO PRN for fever] Antipyretics (eg, acetaminophen) and other comfort measures (eg, repositioning, oral hydration, pain medication) can be provided after antibiotic therapy is initiated. [C. Lactated Ringer IV bolus once] IV fluid administration (eg, Lactated Ringer IV bolus) is a supportive measure used to help resolve tachycardia and promote adequate hydration, but it does not take priority over antibiotic administration. [D. Methylergonovine PO every 4 hours] To promote uterine involution, uterotonics (eg, PO methylergonovine) may be prescribed. Although uterine involution can promote drainage of purulent lochia, methylergonovine does not take priority over antibiotics, which are needed to treat the cause of infection. Educational objective:Postpartum endometritis is an infection of the endometrium (uterine lining) and is characterized by fever, chills, tachycardia, uterine tenderness, and foul-smelling or purulent lochia. The nurse's priority intervention is initiation of broad-spectrum antibiotics to treat the infection and reduce the risk of complications (eg, abscess, peritonitis). Subsequent interventions include antipyretics, IV fluids, and (possibly) uterotonics for uterine subinvolution.

A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate's vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next? Vital signs Temperature 98.6 F (37 C) Heart rate 146/min Respirations 42/min O2 saturation 98% A. Call the health care provider immediately B. Document the finding C. Place the neonate in a knee-chest position D. Provide oxygen to the neonate

Correct Answer: B. Document the finding Atrioventricular (AV) canal defect is a cardiac anomaly often associated with trisomy 21 (Down syndrome). As an echocardiogram is already scheduled for that day, documenting the finding would be the appropriate action for the nurse to complete at this time. Incorrect Answers: [A. Call the health care provider immediately] The neonate has stable vital signs, and the echocardiogram will be completed. This is not an emergency and the health care provider does not need to be contacted immediately. [C. Place the neonate in a knee-chest position] A knee-chest position is used to treat episodes of hypoxia and cyanosis in infants and young children with tetralogy of Fallot (TOF). This neonate likely has an AV canal defect, not TOF. There is also no indication of cyanosis or hypoxia that would require knee-chest positioning. [D. Provide oxygen to the neonate] The normal respiratory rate in a neonate is 30-60/min; pulse can be up to 160/min. The vital signs are stable, and the oxygen saturation level is appropriate for a neonate. Educational objective:Trisomy 21 (Down syndrome) is often associated with the cardiac anomaly AV canal defect. Findings typically include a loud murmur that requires no immediate action when vital signs are stable. After the neonate grows in size and can better tolerate the invasive procedure, surgery will correct the anomaly.

The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse? A. Discomfort during fundal palpation B. Foul-smelling lochia C. Oral temperature 100.1 F (37.8 C) D. White blood cell count 24,000/mm^3 (24.0 x 10^9/L)

Correct Answer: B. Foul-smelling lochia A foul odor of lochia suggests endometrial infection. This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical examinations. The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness. Incorrect Answers: [A. Discomfort during fundal palpation] Palpation of the postpartum uterine fundus is commonly uncomfortable. If the client has increasing pain, further evaluation is needed. [C. Oral temperature 100.1 F (37.8 C)] Major signs and symptoms of endometrial infection include temperature >100.4 F (38.0 C), chills, malaise, excessive uterine tenderness, and purulent, foul-smelling lochia. During the first 24 hours postpartum, temperature is normally elevated, but a reading of >100.4 F (38 C) requires further evaluation. [D. White blood cell count 24,000/mm^3 (24.0 x 10^9/L)] The white blood cell count is normally elevated during the first 24 hours postpartum (up to 30,000/mm3 [30.0 x 109/L]). Leukocyte levels that are not decreasing require further evaluation. Educational objective:Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and white blood cell count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation.

The nurse is monitoring a newborn with skin discoloration in the lumbar area. Which action by the nurse is appropriate? Click the exhibit button for additional information. [Exhibit: Picture of Congenital Dermal Melanocytosis] A. Check the infant's hemoglobin, hematocrit, and platelet levels B. Measure and document the size and location of the markings C. Notify the registered nurse of the markings immediately D. Review the delivery record for evidence of a traumatic birth

Correct Answer: B. Measure and document the size and location of the markings Congenital dermal melanocytosis (Mongolian spots) is a benign skin discoloration most often seen in newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian). Mongolian spots are usually bluish-gray, typically found on the back or buttocks, and fade over the first 1-2 years of life. Because they are easily misidentified as bruises, it is important for the nurse to measure and document the area for reference during future health care assessments. Incorrect Answers: [A. Check the infant's hemoglobin, hematocrit, and platelet levels] Mongolian spots are common birthmarks not associated with abnormal laboratory work. [C. Notify the registered nurse of the markings immediately] Mongolian spots are benign, and notifying the registered nurse immediately is not indicated. [D. Review the delivery record for evidence of a traumatic birth] Although often mistaken for bruises, Mongolian spots are normal skin variations and are not due to trauma. Educational objective:Congenital dermal melanocytosis (Mongolian spots) is a benign skin discoloration (ie, bluish-gray) typically found on the back or buttocks. It is more common in newborns of ethnicities with darker skin tones. The spots may be misidentified as bruising in future assessments and should be documented to avoid misinterpretation of findings.

A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention? A. Lochia that soaks a perineal pad every 2 hours B. Persistent headache with blurred vision C. Red, painful nipple on one breast D. Strong-smelling vaginal discharge

Correct Answer: B. Persistent headache with blurred vision Persistent headache and blurred vision could indicate postpartum preeclampsia. The majority of clients with preeclampsia develop symptoms before birth; however, a small percentage do not develop the complication until several days after birth. This potentially serious condition can rapidly worsen, leading to seizures and death if left untreated. Additional signs and symptoms may include high blood pressure, proteinuria, and edema. Incorrect Answers: [A. Lochia that soaks a perineal pad every 2 hours] In the immediate postpartum period, lochia should be assessed frequently to monitor for postpartum hemorrhage. Soaking a perineal pad in ≤1 hour would indicate excessive bleeding that requires urgent intervention. [C. Red, painful nipple on one breast] Red or painful nipples in a breastfeeding client may be the result of incorrect latch and/or improper breastfeeding technique. The nurse should observe the client while breastfeeding, identify any problems with the newborn's latch, and obtain additional assessment from a lactation consultant, if appropriate. [D. Strong-smelling vaginal discharge] Strong- or foul-smelling vaginal discharge may represent an infection (eg, endometritis). This assessment finding indicates the need for further evaluation but is not immediately life-threatening. Educational objective:Preeclampsia can develop in the postpartum period several days after birth. Clients in the postpartum period with signs and symptoms of preeclampsia (eg, edema, persistent headache, vision changes, elevated blood pressure) should be evaluated and treated immediately.

A client at 39 weeks gestation with preeclampsia has a blood pressure of 170/100 mm Hg, 2+ proteinuria, and moderate peripheral edema. Immediately after hospital admission, she develops seizures and uterine contractions. Magnesium sulfate is prescribed. Which finding indicates that the drug has achieved the desired therapeutic effect? A. Blood pressure <130/80 mm Hg B. Seizure activity stops C. Urine has 1+ protein D. Uterine contractions stop

Correct Answer: B. Seizure activity stops Preeclampsia is a systemic disease characterized by hypertension and proteinuria after the 20th gestational week with unknown etiology. Eclampsia is the onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia. Delivery is the only cure for preeclampsia-eclampsia syndrome. Magnesium sulfate is a central nervous system depressant used to prevent/control seizure activity in preeclampsia/eclampsia clients. During administration, the nurse should assess vital signs, intake and output, and monitor for signs of magnesium toxicity (eg, decreased deep-tendon reflexes, respiratory depression, decreased urine output). A therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic client. Incorrect Answers: [A. Blood pressure <130/80 mm Hg] Hypertension is a sign of preeclampsia. Hydralazine (Apresoline), methyldopa (Aldomet), or labetalol (Trandate) is used to lower blood pressure (BP) if needed (usually considered when BP is >160/110 mm Hg). [C. Urine has 1+ protein] Proteinuria is a symptom of preeclampsia. Control of hypertension and delivery will reduce the protein level. Magnesium sulfate is not prescribed to decrease proteinuria. [D. Uterine contractions stop] Tocolytic drugs (eg, terbutaline, magnesium sulfate, indomethacin, nifedipine) are used to suppress uterine contractions in preterm labor, allowing pregnancy to be prolonged for 2-7 days so that corticosteroid administration can improve fetal lung maturity. This client is at term, and there is no need to delay delivery. Educational objective:Magnesium sulfate is prescribed for clients with preeclampsia to prevent seizure activity. A therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic client.

A client postpartum 3 days scheduled for discharge today was given education about diaper changes yesterday. The client says to the nurse, "I'm so glad you are here. I think my baby has a dirty diaper. I can't change it as well as you can. Will you change my baby's diaper for me?" What is the nurse's best response? A. Reassure the mother that it takes time to learn how to care for a baby while quickly changing the diaper B. Suggest that the mother change the diaper as the nurse watches C. Tell the mother that it is time to take over changing the baby's diaper as she will have to do it once discharged D. Tell the mother that the nurse will change the baby's diaper while she watches

Correct Answer: B. Suggest that the mother change the diaper as the nurse watches According to the Rubin theory, there are 3 phases of postpartum adaptation to motherhood. · Taking-in: In the first 24-48 hours postpartum, the mother is physically recovering from childbirth. During this time, she is more dependent on the health care team to help with care of the baby. · Taking-hold: During 2-10 days postpartum, the mother still is learning the technical skills of mothering but may feel inadequate. · Letting-go: After 10 days postpartum, the mother becomes comfortable with the new role. Research indicates that new mothers adapt to their role today more quickly than they did during the 1960s, when the Rubin theory was developed. This mother is still learning to care for the newborn. Therefore, letting her change the diaper will allow the nurse to assess her diaper changing skills and provide education as needed. Incorrect Answers: [A. Reassure the mother that it takes time to learn how to care for a baby while quickly changing the diaper] If the nurse takes over this essential task and delays the client's need to be comfortable in the role of a mother, it may reinforce the client's perception of not being capable or competent. [C. Tell the mother that it is time to take over changing the baby's diaper as she will have to do it once discharged] This response would give the mother opportunity to demonstrate the new skill, but it is not a good example of therapeutic communication. [D. Tell the mother that the nurse will change the baby's diaper while she watches] The mother was taught how to change a diaper the previous day. If the nurse performs the task, the mother may feel incompetent and unable to learn. Educational objective:There are 3 distinct phases of postpartum adjustment to motherhood, as outlined by Rubin.

Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching? A. "I should avoid resuming sexual intercourse until after my vaginal bleeding has stopped." B. "I should expect vaginal dryness and use water-soluble lubricants, especially if I'm breastfeeding." C. "I will begin using condoms to prevent pregnancy once menses returns." D. "I will try to feed my baby before my partner and I engage in sexual activity."

Correct Answer: C. "I will begin using condoms to prevent pregnancy once menses returns." Initiating an open discussion about sexual activity after childbirth allows the nurse to provide anticipatory guidance and recognize individual client concerns (eg, discomfort, fatigue, fear, body image). The nurse should plan to reinforce the use of contraception because many clients resume sexual activity before their postpartum checkup (4-6 weeks after birth), when contraception methods are usually prescribed. Ovulation may occur as early as 4 weeks after birth and before resumption of menses, especially in clients who formula feed. Clients should be encouraged to use a barrier contraceptive such as condoms to prevent pregnancy until another form of birth control can be prescribed. Incorrect Answers: [A. "I should avoid resuming sexual intercourse until after my vaginal bleeding has stopped."] Sexual activity may be resumed once lacerations/episiotomy are healed, and vaginal bleeding has stopped. For clients with no birth complications, risk of infection or bleeding is low at ≥2 weeks postpartum. [B. "I should expect vaginal dryness and use water-soluble lubricants, especially if I'm breastfeeding."] Sexual arousal takes more time for most postpartum clients due to hormonal changes. Lactating clients may especially experience symptoms of estrogen deficiency (eg, vaginal dryness). Vaginal lubrication is recommended to increase comfort. [D. "I will try to feed my baby before my partner and I engage in sexual activity."] Sexual activity may be inhibited by the couple's sense of responsibility for newborn needs. In addition, sexual arousal may stimulate leakage of breast milk. Feeding the newborn before sexual activity helps alleviate these concerns/distractions. Educational objective:Many postpartum clients resume sexual activity before their postpartum checkups (4-6 weeks after birth). Encouraging the use of barrier contraceptives (eg, condoms) to prevent pregnancy is important because ovulation may occur as early as 4 weeks after birth and before resumption of menses.

The nurse is reinforcing teaching about infant safety to a class of expectant parents. Which statement by a participant indicates a need for further instruction? A. "I will make sure there is a firm mattress in the crib." B. "I will put my baby to bed with a pacifier." C. "I will tie bumper pads to the sides of the crib to protect my baby's head." D. "I will use a sleeping sack or a thin blanket that I tuck to cover my baby."

Correct Answer: C. "I will tie bumper pads to the sides of the crib to protect my baby's head." Sudden infant death syndrome (SIDS) is the leading cause of death among infants age 1 month to 1 year. Nurses play a crucial role in teaching parents about child care practices that reduce the risk of SIDS, which include the following: · Place infants age <1 year for sleep on their backs on a firm surface. The prone or side-lying position should never be used. Infants should not share a bed with parents/caregivers. · Avoid soft objects such as stuffed animals, heavy blankets, and pillows in the infant's bed. A thin blanket tucked into the sides and bottom of the mattress can be used to cover the infant. · Avoid bumper crib pads, which have not been shown to be effective in preventing infant injury and likely increase the risk of SIDS. · Maintain a smoke-free environment. · Avoid overheating; if the infant is wearing a sleeper ("onesie") or a sleeping sack, even a tucked blanket may not be necessary. A fan may help reduce the temperature and circulate air in a warm room. · Use a pacifier (age >1 month to ensure that breastfeeding has been established for those who are being breastfed) when placing the infant for sleep. · Breastfeed and keep the infant's immunizations up to date. Incorrect Answers: [A. "I will make sure there is a firm mattress in the crib."] Infants should sleep on a firm surface/mattress. [B. "I will put my baby to bed with a pacifier."] Placing infants for sleep with a pacifier may reduce the risk of SIDS. [D. "I will use a sleeping sack or a thin blanket that I tuck to cover my baby."] If a blanket is used, it should be thin and tucked underneath the mattress around the sides and end. Educational objective:The risk of sudden infant death syndrome can be reduced by following safe sleep practices and prevention guidelines. Infants should always be placed on their backs on a firm surface without loose bedding or toys. Preventive measures include maintaining a smoke-free environment, avoiding overheating, promoting breastfeeding, and having the infant use a pacifier.

The nurse is reinforcing teaching about breastfeeding to a postpartum client. Which statement by the client indicates a correct understanding of teaching? A. "I will feed my baby for 5-10 minutes on each breast." B. "I will hold my baby on their back with the head turned toward my breast." C. "If I need to reposition my baby's latch, I will use my finger to break the suction first." D. "The baby's mouth should grasp only the nipple, not the areola."

Correct Answer: C. "If I need to reposition my baby's latch, I will use my finger to break the suction first." Sore nipples and painful breastfeeding are common reasons clients discontinue breastfeeding. Teaching proper technique helps clients continue breastfeeding, promotes comfort for the mother, and ensures adequate newborn nutrition. Key principles of proper breastfeeding and latch technique include: · Breastfeed every 2-3 hours on average (8-12 times/day) · Breastfeed "on demand" whenever the newborn exhibits hunger cues (eg, sucking, rooting reflex) · Position the newborn "tummy to tummy" with mouth in front of nipple and head in alignment with body · Ensure a proper latch (ie, grasps both nipple and part of areola) · Feed for at least 15-20 minutes per breast or until the newborn appears satisfied · Insert a clean finger beside the newborn's gums to break suction before unlatching · Alternate which breast is offered first at each feeding Incorrect Answers: [A. "I will feed my baby for 5-10 minutes on each breast."] Five to ten minutes per breast may be insufficient to feed and may lead to inadequate breast emptying and insufficient nutritional intake. [B. "I will hold my baby on their back with the head turned toward my breast."] Awkward manipulation of the newborn's head while breastfeeding makes it difficult for the newborn to latch and feed comfortably. The mother should support the newborn's head and keep it in alignment with the body in all breastfeeding positions. [D. "The baby's mouth should grasp only the nipple, not the areola."] If the newborn grasps the nipple only, breastfeeding will be painful due to pinching. Educational objective:If the newborn latches incorrectly or needs to be removed from the breast, the client should insert a finger to break suction before unlatching. When removed from the breast incorrectly, nipple trauma may occur, leading to sore nipples and painful breastfeeding.

The nurse is contributing to the plan of care for a client with diabetes who reports breast tenderness, vaginal discharge, and urinary frequency. Which action is most important to include in the plan of care? A. Ask if the client performs breast self-exams B. Ask the client about characteristics of vaginal discharge C. Determine the date of the client's last menstrual period D. Review the client's home blood sugar logs

Correct Answer: C. Determine the date of the client's last menstrual period Subjective (presumptive) signs of pregnancy are self-reported by the client. This client's symptoms (ie, breast tenderness, vaginal discharge, urinary frequency) could originate from pathologic causes (eg, urinary tract infection [UTI], sexually transmitted infection) but, collectively, may be indicative of early pregnancy. It is most important for the nurse to review the client's menstrual history if any possible signs or symptoms of early pregnancy are reported. Incorrect Answers: [A. Ask if the client performs breast self-exams] Regular breast self-exams are an important part of breast self-awareness and may alert the client to pathologic breast changes. However, breast tenderness is a common sign of early pregnancy, which should be considered first. [B. Ask the client about characteristics of vaginal discharge] Leukorrhea (ie, whitish, mucoid vaginal discharge) increases during pregnancy in response to rising hormone levels. The nurse should ask the client about color, odor, and consistency of discharge to identify symptoms of infection, but this is not more important than collecting data about the client's menstrual history. [D. Review the client's home blood sugar logs] Increased urinary frequency may result from hyperglycemia, and clients with diabetes are at increased risk for infections (eg, UTI, yeast infection). Reviewing home blood sugar logs would help to identify the client's level of glycemic control over time but would not address the other symptoms that the client reported. Educational objective:Subjective (self-reported) signs of pregnancy may include leukorrhea, breast tenderness, and urinary frequency. It is most important to review the client's menstrual history if any possible signs or symptoms of early pregnancy are reported.

The registered nurse is preparing to administer oxytocin to induce labor in a client. The practical nurse assists the registered nurse and recognizes that the oxytocin infusion can lead to which of the following conditions? A. Decreased postpartum hemorrhage B. Delayed milk production C. Fetal distress and cesarean birth D. High risk of placenta previa

Correct Answer: C. Fetal distress and cesarean birth Oxytocin (a uterine stimulant) is used to induce labor. Contractions can become too strong after oxytocin is administered and lead to reduced placental blood flow. This can result in non-reassuring fetal heart rate (FHR) patterns (eg, late decelerations, fetal bradycardia, tachycardia, minimal variability). These non-reassuring FHR patterns may necessitate emergency cesarean birth, which would not have been required had labor not been induced. Incorrect Answers: [A. Decreased postpartum hemorrhage] After birth, the nurse should observe for postpartum hemorrhage, especially if the client received oxytocin for a long period. The uterine muscles become fatigued and may not contract effectively to compress vessels at the placental site. [B. Delayed milk production] Oxytocin, a hormone secreted by the pituitary, triggers the milk ejection/let-down reflex (release of milk from the alveoli into the ducts). Prolactin is the pituitary hormone regulating milk production. Exogenous oxytocin has no known effects on milk production. [D. High risk of placenta previa] Greater uterine activity from oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa is abnormal implantation and is unrelated to oxytocin infusion. Educational objective:Oxytocin, a uterine stimulant, is frequently used to induce labor. Oxytocin infusion can result in quick delivery, but it increases the risk for unnecessary cesarean birth (due to fetal heart rate abnormalities), postpartum hemorrhage, and placental abruption.

A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2-hour-old newborn, which clinical finding requires the nurse to intervene? A. Cyanosis of hands and feet B. Heart rate of 165/min while crying C. Jitteriness D. Respirations of 60/min

Correct Answer: C. Jitteriness Newborns whose mothers have diabetes mellitus are at increased risk for complications after birth, most commonly hypoglycemia but also hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. During intrauterine life, exposure to elevated maternal glucose levels causes the fetus to produce high levels of insulin. After birth, the newborn loses the maternal supply of glucose but continues to produce high levels of insulin, as during intrauterine life, increasing the risk of hypoglycemia (ie, blood glucose <40-45 mg/dL [2.2-2.5 mmol/L]). Symptoms of hypoglycemia, usually noted in the first several hours after birth, include jitteriness, irritability, hypotonia, apnea, lethargy, and temperature instability. Immediate intervention is required to prevent neurologic damage. Incorrect Answers: [A. Cyanosis of hands and feet] Cyanosis of the hands and feet (acrocyanosis) is a benign, transient finding during the transition to extrauterine life. [B. Heart rate of 165/min while crying] The newborn's heart rate should be assessed by auscultation of the apical pulse for a full minute. A normal heart rate for a newborn is 110-160/min but may increase to 180/min during crying or may decrease to 100/min during sleep. [D. Respirations of 60/min] The newborn's respiratory pattern should be assessed for one full minute. Normal newborn respirations are 30-60/min and decrease to an average of 40/min after the transition period. Educational objective:Newborns whose mothers have diabetes mellitus are at increased risk for hypoglycemia, especially in the first several hours after birth. A common symptom of newborn hypoglycemia is jitteriness. Newborn hypoglycemia requires immediate intervention to prevent neurologic damage.

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene? A. Assesses the baby's position and sucking behavior during breastfeeding B. Demonstrates to the mother how to use an electric breast pump C. Provides supplemental formula feedings until improved breastfeeding occurs D. Shows the mother how to hand express breast milk

Correct Answer: C. Provides supplemental formula feedings until improved breastfeeding occurs Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast surgery; poor infant latch or sucking reflex; or the use of formula feeding. The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates it interferes with the mother's ability to exclusively breastfeed (Option 3). Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration, excessive weight loss) and if alternate breastfeeding techniques are unsuccessful. A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk supply is established and is also useful when a breast pump is not available. If ineffective breastfeeding occurs, the nurse should: · Assess the baby's sucking reflex and physical condition · Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) · Teach how to express milk by hand and use an electric pump to enhance milk production · Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer than 24 hours Educational objective:Supplemental formula feedings and the use of artificial nipples are avoided when ineffective breastfeeding is present, as they interfere with the mother's ability to breastfeed exclusively. Supplemental formula feeds are only used after a full assessment and if other techniques are unsuccessful.

A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency? A. Frequent vomiting since birth B. Tiny blood streaks in the vomit C. Vomit that is green D. Vomiting through the nose

Correct Answer: C. Vomit that is green Bile made by the liver is green and is released into the duodenum on eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, it may come back up as green vomit. A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis. Incorrect Answer: [A. Frequent vomiting since birth] Newborns vomit or spit up frequently as they adjust to eating and digesting food. They also have a loose lower esophageal sphincter that allows food to come up from the stomach easily. Hydration status and weight gain should be monitored. [B. Tiny blood streaks in the vomit] Tiny blood streaks may be noted due to rupture of pressured esophageal veins from frequent vomiting. This is not a cause for concern unless the vomit contains a large amount of blood or blood-streaked vomiting persists. Scant amounts seen in vomit can be normal. [D. Vomiting through the nose] It is not uncommon for a newborn to have vomiting through the nose because the esophagus is connected to the nose and mouth. The vomit comes up through the esophagus and, if forceful enough, will come out of both orifices. Educational objective:It is common for newborns to vomit frequently as they learn to eat and digest. Hydration status and weight gain should be monitored. Green vomit represents bile from the intestine, which could indicate a bowel obstruction.

The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching? A. "I can expect the cord to turn black in a few days." B. "I should let the cord fall off by itself." C. "I will give my newborn sponge baths until the cord falls off." D. "I will secure the diaper over the cord to protect it."

Correct Answer: D. "I will secure the diaper over the cord to protect it." Proper care of the umbilical cord stump facilitates healing and reduces infection and bleeding risks. The cord clamp is removed after the stump stops bleeding and begins to dry, usually around 24 hours after birth. The primary goal is to keep the stump dry and clean. Historically, cord stumps were cleaned with antiseptics (eg, alcohol, chlorhexidine), but current recommendations are to clean the stump with water and dry well to prevent skin irritation. Securing the diaper over the cord increases the risk for contamination with urine and feces, which may promote infection (ie, omphalitis) and should be avoided. Key principles of cord care include: · Keep the cord stump open to air to allow for adequate drying. · Expect the cord to shrivel and turn black within 2-3 days and fall off within 1-2 weeks. · Allow the cord to fall off on its own, even if barely attached, to avoid bleeding. · Give sponge baths with warm water instead of tub baths until the cord has fallen off. · Keep diapers folded below the cord to keep it dry and prevent contamination with urine or feces. · Report signs of infection (eg, redness, purulent drainage, swelling) to the health care provider. Educational objective:The primary goal of umbilical cord care is to keep the cord stump dry and clean. Sponge baths are given until the stump falls off in approximately 1-2 weeks. Diapers are folded beneath the cord to keep it dry and avoid contamination.

The nurse is evaluating a client's understanding of postcircumcision care for a 24-hour-old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching? A. "Bleeding should be no larger than the size of a quarter." B. "I should cleanse the glans with warm water occasionally." C. "I should expect at least 2 wet diapers in the next 24 hours." D. "Yellow exudate on the glans penis indicates infection."

Correct Answer: D. "Yellow exudate on the glans penis indicates infection." Newborn circumcision is a procedure that removes the foreskin from the glans penis using a clamp (eg, Gomco) or plastic ring (eg, PlastiBell). Circumcision is typically performed near discharge to ensure that the newborn is stable. Circumcision care includes: · Washing hands before providing care. · Applying petroleum jelly to the glans penis at diaper changes (unless PlastiBell was used) for 3-7 days to prevent the exposed glans from adhering to the diaper until the site heals. The circumcision site typically heals within 7-10 days. · Expecting yellow exudate on the penis after the first day, a normal part of the healing process. Exudate should not be removed forcefully and disappears in 2-3 days. Swelling, increasing redness, odor, or abnormal discharge may indicate infection. Incorrect Answers: [A. "Bleeding should be no larger than the size of a quarter."] Bleeding that exceeds the size of a quarter is a concern. [B. "I should cleanse the glans with warm water occasionally."] Using warm water (without soap) to remove urine/feces during diaper changes or at least twice daily is needed to keep the site clean. Alcohol-based wipes prevent healing and cause discomfort. [C. "I should expect at least 2 wet diapers in the next 24 hours."] In the first 48 hours of life, 2-6 wet diapers every 24 hours are expected. By 3-4 days, 6-8 wet diapers every 24 hours are expected. The nurse should notify the health care provider if there is inadequate voiding or no voiding within 6-8 hours of circumcision, which may indicate urethral damage or excessive swelling. Educational objective:Yellow exudate on the glans penis indicates normal healing. Unusual swelling, increasing redness, odor, abnormal discharge, excessive bleeding, or absent/decreased urine output should be reported.

The practical nurse is collecting data on several clients waiting to be seen in the prenatal clinic. Which client situation is most important to report to the registered nurse? A. 18 weeks gestation client taking ceftriaxone and reporting mild diarrhea B. 22 weeks gestation client with twins who is taking acetaminophen twice a day C. 28 weeks gestation client taking metronidazole who has dark-colored urine D. 32 weeks gestation client taking ibuprofen for moderate back pain

Correct Answer: D. 32 weeks gestation client taking ibuprofen for moderate back pain Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, indomethacin, or naproxen, inhibit prostaglandin synthesis and can be taken to decrease pain and inflammation or reduce a fever. Ibuprofen is assigned the pregnancy category C through 29 weeks gestation and pregnancy category D starting at 30 weeks gestation. It must be avoided starting at 30 weeks gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus and prolonged labor in the client. Prior to 30 weeks gestation, ibuprofen should be taken only if the benefits outweigh the risks and under the supervision of a health care provider. Interventions to treat back and sciatic pain during pregnancy include: 1. Acetaminophen: This pain reliever may be taken during pregnancy for discomfort and to reduce fever. Oral and rectal acetaminophen is assigned the pregnancy category B (Option 2). 2. Heat: A warm bath or compress may help relieve discomforts during pregnancy. 3. Reposition: Lying on the unaffected side or changing position may help relieve pain. Incorrect Answers: [A. 18 weeks gestation client taking ceftriaxone and reporting mild diarrhea] Beta-lactam antibiotics, such as amoxicillin and most cephalosporins (ceftriaxone [Rocephin]), are assigned the pregnancy category B. Diarrhea is a common side effect of beta-lactams. Although this client's diarrhea is not the first priority, it should be reported to the registered nurse promptly as it could indicate pseudomembranous (Clostridium difficile) colitis or lead to dehydration. [B. 22 weeks gestation client with twins who is taking acetaminophen twice a day] Oral and rectal acetaminophen is assigned the pregnancy category B. [C. 28 weeks gestation client taking metronidazole who has dark-colored urine] Metronidazole (Flagyl) is an anti-infective assigned the pregnancy category B. Clients should be taught that metronidazole might cause their urine to turn dark. Educational objective:Nonsteroidal anti-inflammatory drugs must be avoided starting at 30 weeks gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus and prolonged labor in the client. Prior to 30 weeks gestation, they may be taken only under the close supervision of a health care provider.

A client gives birth within an hour of arriving at the labor and delivery unit and delivers the placenta 5 minutes later. During assessment, the nurse notes that the uterus is midline and boggy. Which action should the nurse take first? A. Check for pooled blood under buttocks B. Increase IV oxytocin infusion rate C. Monitor blood pressure and pulse D. Perform firm fundal massage

Correct Answer: D. Perform firm fundal massage After delivery of the placenta, the uterus begins the process of involution. The uterus should be firmly contracted, midline, and at or slightly below the umbilicus. A boggy uterus indicates uterine atony, a state in which the uterus fails to contract adequately and compress vessels at the placental detachment site. This may lead to excessive blood loss and clots. The initial nursing action for uterine atony with a midline fundus is fundal massage, which stimulates contraction of the uterine smooth muscle. If the uterus becomes firm with massage, the nurse should continue to monitor uterine tone, position, and lochia at least every 15 minutes in the initial hour after birth. Incorrect Answers: [A. Check for pooled blood under buttocks] The nurse should monitor lochia frequently in the immediate postpartum period, especially underneath the client where blood can pool and go undetected. However, fundal massage is most important because uncorrected uterine atony will eventually result in excessive blood loss. [B. Increase IV oxytocin infusion rate] Uterotonics (eg, oxytocin, methylergonovine) stimulate the uterus to contract. If the uterus fails to contract despite massage, further administration of uterotonics is indicated. [C. Monitor blood pressure and pulse] Monitoring blood pressure and pulse are important interventions for postpartum clients, especially those at risk for excessive blood loss. This intervention may be delayed until after fundal massage to reduce further blood loss. Educational objective:After placenta delivery, the fundus should be firm, midline, and at or slightly below the umbilicus. The initial nursing action to correct uterine atony with a midline, boggy uterus is fundal massage.

The practical nurse (PN) is assisting with a client who is undergoing labor induction with misoprostol. The PN notes late decelerations and minimal variability on the fetal heart rate tracing. After notifying the registered nurse, what should the PN do first? A. Administer 10 L/min oxygen by face mask B. Examine the perineum to check for bloody show C. Palpate the client's abdomen D. Reposition the client to a side-lying position

Correct Answer: D. Reposition the client to a side-lying position Misoprostol (Cytotec) is a prostaglandin E1 used for cervical ripening (softening of the cervix) during labor induction. A common adverse effect of misoprostol is uterine tachysystole (ie, >5 contractions in 10 minutes), which may decrease fetal oxygenation and cause a nonreassuring fetal heart rate (FHR) (eg, late decelerations, fetal tachycardia, minimal variability). If nonreassuring FHR patterns occur, the practical nurse (PN) should notify the registered nurse (RN) and initiate intrauterine resuscitation interventions. The first intervention is to reposition the client to a side-lying position to increase placental perfusion and improve fetal oxygenation Incorrect Answers: [A. Administer 10 L/min oxygen by face mask] Administering 8-10 L/min of oxygen via face mask and an IV fluid bolus under RN supervision helps improve oxygen availability to the fetus and placental perfusion. However, these interventions should be performed after repositioning the client laterally. [B. Examine the perineum to check for bloody show] "Bloody show," or blood-tinged mucus, at the perineum may indicate that the client is progressing in labor; however, examining the perineum does not resolve late decelerations of the FHR. [C. Palpate the client's abdomen] Palpating the abdomen allows the nurse to monitor for appropriate uterine resting tone (ie, soft) and duration of the resting phase between contractions (ie, ≥60 seconds), but it is performed after intrauterine resuscitation interventions. Educational objective:Misoprostol (Cytotec) is used for cervical ripening during labor induction. A common adverse effect is uterine tachysystole that may cause nonreassuring fetal heart rate patterns. The practical nurse's first intervention after notifying the registered nurse is to reposition the client to a side-lying position.

The practical nurse (PN) is assisting with care for a 1-day-old client who is irritable, feeding poorly, and only sleeping for very short intervals. The newborn's mother has been taking hydrocodone on a regular basis for several years. When collaborating with the registered nurse to develop the plan of care, which intervention should the PN include? A. Avoid giving the newborn a pacifier B. Position the newborn supine after feeding C. Stimulate the newborn with light regularly D. Swaddle and gently rock the newborn

Correct Answer: D. Swaddle and gently rock the newborn The newborn of a mother who is opioid-dependent (eg, heroin, methadone, hydrocodone) is at high risk for neonatal abstinence syndrome (NAS) or drug withdrawal secondary to in utero exposure to maternal substance abuse. Opioid withdrawal typically manifests within 24-48 hours after birth. Clinical manifestations of withdrawal include irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting, and poor feeding. The newborn with NAS is at risk for skin excoriation from excessive movement caused by hyperactivity and restlessness. The nurse should swaddle the newborn with the arms and legs flexed to prevent skin damage from excessive movement and minimize stimulation. If signs of overstimulation (eg, sneezing, arching) continue, then gentle, rhythmic rocking may soothe the newborn. Incorrect Answers: [A. Avoid giving the newborn a pacifier] Ineffective, unorganized sucking patterns are common in newborns with NAS. Between feedings, a pacifier may soothe the newborn and help establish an organized sucking pattern. [B. Position the newborn supine after feeding] Regurgitation is common in newborns with NAS. The parent should hold the newborn upright shortly after feeding to reduce the risk of vomiting and aspiration. [C. Stimulate the newborn with light regularly] The nurse should place the newborn in a quiet, dimly lit area and organize tasks to minimize stimulation (eg, cluster care). Educational objective:The newborn of a mother who is opioid-dependent is at high risk for neonatal abstinence syndrome. Swaddling and gentle, rhythmic rocking can soothe the newborn, minimize stimulation, and prevent skin excoriation from excessive movement caused by hyperactivity and restlessness.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? A. Cervical lacerations B. Inversion of the uterus C. Uterine atony D. Vaginal hematoma

Correct Answer: D. Vaginal hematoma A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma. Incorrect Answers: [A. Cervical lacerations] Cervical lacerations should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage. Severe pain or a feeling of fullness is not associated with cervical lacerations. [B. Inversion of the uterus] Complete inversion of the uterus presents with a large, red mass protruding from the introitus. [C. Uterine atony] Uterine atony presents with a boggy uterus on palpation and an increase in vaginal bleeding. Educational objective:Vaginal hematomas are formed following trauma to the tissues of the perineum during vaginal delivery (eg, vacuum- or forceps-assisted delivery, episiotomy). The client reports severe pain or a persistent feeling of fullness in the region. Assessment shows a firm, midline uterine fundus with minimal or unchanged vaginal bleeding.

The nurse is monitoring a newborn. Which of the following clinical findings should the nurse recognize as expected? Select all that apply. A. Cyanosis of the hands and feet B. Decreased muscle tone C. Heart rate 150/min D. Sacral dimple with a small skin tag E. Single artery in the umbilical cord

Correct Answers: A and C Nurses caring for newborns must be able to distinguish between normal physiologic variations and unexpected findings that require further assessment. Expected findings and normal variations in newborns include: · Bluish discoloration of the hands, feet, and around the mouth (ie, acrocyanosis), which is a common, harmless finding during the first 24 hours after birth and through the first week of life when exposed to cold · Heart rate of 110-160/min when awake and calm; heart rate may further range from 80/min during rest to 180/min when crying or agitated · Firm, flat, and well-distinguished anterior and posterior fontanels (the membrane-filled spaces between the cranial bones) Incorrect Answers: [B. Decreased muscle tone] Newborns normally have increased muscle tone and will resist movement of the extremities. Decreased muscle tone (ie, hypotonia) is an abnormal finding that may indicate a congenital neurological abnormality (eg, Down syndrome) or spinal injury. [D. Sacral dimple with a small skin tag] Sacral dimples, with or without tufts of hair or skin tags, are associated with spina bifida occulta, which is an incomplete closure of vertebrae that cannot be seen externally. [E. Single artery in the umbilical cord] The presence of a single umbilical artery is associated with an increased risk of congenital defects, particularly of the kidneys and heart. Normal umbilical cords contain 2 arteries and 1 vein. Educational objective:Normal findings in a newborn assessment include blue discoloration of the hands and feet (acrocyanosis) and heart rate of 110-160/min. Decreased muscle tone, sacral dimple, or single artery in the umbilical cord are abnormal findings that should be reported for further assessment.

A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? Select all that apply. A. Influenza injection B. Influenza nasal spray C. Measles, mumps, and rubella D. Tetanus, diphtheria, and pertussis E. Varicella

Correct Answers: A and D Health promotion during pregnancy includes the administration or avoidance of certain vaccines to decrease risks to mother and fetus. Pregnant women have suppressed immune systems and are at increased risk for illness and subsequent complications. Some viruses (eg, rubella, varicella) can cause severe birth defects if contracted during pregnancy. Inactivated vaccines contain a "killed" version of the virus and pose no risk of causing illness from the vaccine. Some vaccines contain weakened (ie, attenuated) live virus and pose a slight theoretical risk of contracting the illness from the vaccine. For this reason, women should not receive live virus vaccines during pregnancy or become pregnant within 4 weeks of receiving such a vaccine. The tetanus, diphtheria, and pertussis (Tdap) vaccine is recommended for all pregnant women between the beginning of the 27th and the end of the 36th week of gestation as it provides the newborn with passive immunity against pertussis (whooping cough) During influenza season (October-March), it is safe and recommended for pregnant women to receive the injectable inactivated influenza vaccine regardless of trimester Incorrect Answers: [B. Influenza nasal spray] The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live viruses and are contraindicated in pregnancy. [C. Measles, mumps, and rubella] The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live viruses and are contraindicated in pregnancy. [E. Varicella] The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live viruses and are contraindicated in pregnancy. Educational objective:Inactivated vaccines (eg, inactivated influenza; tetanus, diphtheria, and pertussis) may be given during pregnancy to protect pregnant clients from illness and provide the fetus with passive immunity. Live virus vaccines are contraindicated in pregnancy.

The nurse is reinforcing education to a group of clients that are pregnant or planning pregnancy. Which of the following client statements about alcohol use in pregnancy should concern the nurse? Select all that apply. A. "As long as I don't binge drink, an occasional glass of wine is fine." B. "I drank alcohol heavily before realizing I was pregnant, so there is no benefit to quitting now." C. "If I drink alcohol, my baby may have withdrawal after birth but no permanent damage." D. "It is important to stop drinking while I am trying to conceive." E. "Third-trimester alcohol use is less harmful because the baby is fully developed."

Correct Answers: A, B, C, and E Alcohol consumption during pregnancy is concerning and is reported by 1 in 9 women according to research surveys. Nurses play a significant role in educating clients about the teratogenic risks of alcohol consumption, which include miscarriage, preterm birth, low birth weight, and fetal alcohol spectrum disorders (eg, fetal alcohol syndrome). Fetal alcohol spectrum disorders may not be diagnosed immediately, but a range of permanent neurodevelopmental abnormalities or dysmorphic facial features may occur. During pregnancy, the nurse should screen for substance abuse to identify clients who consume alcohol. The nurse should educate clients that alcohol freely crosses the placenta into the fetal bloodstream, affecting the growth and development of the fetus at any gestational age. Therefore, no amount of alcohol intake during pregnancy is safe (Options 1 and 5). The nurse should also inform clients that discontinuing alcohol intake at any time during pregnancy can improve future outcomes for the child. Incorrect Answer: [D. "It is important to stop drinking while I am trying to conceive."] The nurse should encourage clients who are planning pregnancy to abstain from alcohol to avoid potential exposure of the embryo during a highly critical period of development. Educational objective:Alcohol consumption is concerning in pregnant clients. The nurse should inform clients that no amount of alcohol is safe during pregnancy and that consumption may lead to miscarriage, low birth weight, or fetal alcohol spectrum disorders. Pregnant clients or those planning pregnancy should abstain from alcohol to protect offspring from permanent abnormalities (eg, neurodevelopmental, facial).

A practical nurse is evaluating the external fetal monitoring strip of a laboring primigravida who is at 36 weeks gestation. Which nursing interventions should the practical nurse anticipate? [Exhibit: a fetal heart rate strip depicting late decelerations] A. Administer supplemental oxygen by mask B. Increase the IV fluid rate C. Prepare the client for an amnioinfusion D. Reposition the client to the supine position E. Stop the client's oxytocin infusion

Correct Answers: A, B, and E Late decelerations occur after the onset of a uterine contraction and continue beyond its end. They are caused by uteroplacental insufficiency. The lowest point of a late deceleration occurs near the end of the uterine contraction and may occur with marked hypertonia or increased uterine tone caused by oxytocin. The registered nurse should be notified about late decelerations, and immediate action must be taken. The client should be given oxygen by facemask and repositioned to the right or left side. Oxytocin should be stopped if it is being administered, and the IV fluid rate should be increased. If the deceleration pattern persists or variability becomes abnormal, the nurse should anticipate an imminent delivery. Incorrect Answers: [C. Prepare the client for an amnioinfusion] An amnioinfusion is a transvaginal infusion of an isotonic fluid to compensate for the loss of amniotic fluid (oligohydramnios). [D. Reposition the client to the supine position] The client should be placed on her right or left side to remove the pressure on the inferior vena cava by the gravid uterus and to provide adequate placental perfusion. Supine positioning can obstruct blood flow to the placenta. Educational objective:Late decelerations are caused by uteroplacental insufficiency. A client with late decelerations should be given oxygen by facemask and placed on the right or left side; oxytocin should be stopped if it is being administered, and increased IV fluids must be provided.

The practical nurse is assisting with care for several newborns in the nursery. Which of the following findings are abnormal and need to be reported to the registered nurse? Select all that apply. A. Chest wall retractions B. Flaking skin on the feet C. Head circumference of 13.5 inches (34 cm) D. Jaundice of the head and sclera E. No documentation of voiding in the past 24 hours

Correct Answers: A, D, and E When caring for newborns, the practical nurse should recognize abnormal findings and report them to the registered nurse (RN) for further assessment. Some abnormal newborn findings include: · Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory distress should be evaluated promptly to determine necessary treatment. · Jaundice, especially if noted within the first 24 hours of life (pathologic): Yellowish hues may be noted on the face or eyes initially and may progress caudally. Even physiologic jaundice (>24 hr of life) requires close monitoring to ensure that it does not progress. · No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day of life or in the past 24 hours is concerning for a structural anomaly or dehydration. Incorrect Answers; [B. Flaking skin on the feet] Flaking or peeling skin, known as desquamation, is a normal finding in some newborns. Moisturizers can be applied if desired, but desquamation resolves on its own over several days. [C. Head circumference of 13.5 inches (34 cm)] The average newborn head circumference is approximately 13-14 inches (33-35 cm). The RN should be notified if a newborn has a smaller or larger head circumference, which may indicate an abnormal condition (eg, microcephaly, hydrocephalus). Educational objective:When caring for newborns, the practical nurse should recognize abnormal findings (eg, signs of respiratory distress [eg, chest wall retractions], jaundice, failure to void within 24 hours) and report them to the registered nurse for further assessment.

The labor and delivery nurse is conducting a staff education conference on preterm labor management for clients <34 weeks gestation. Which of the following statements by a participant are appropriate? Select all that apply. A. "Administration of antibiotics is necessary because the status of group B Streptococcus is unknown." B. "Betamethasone is administered to promote fetal lung maturity." C. "Clients in preterm labor require auscultation of fetal heart tones once per shift." D. "I will have equipment ready to assist with artificial rupture of membranes." E. "IV magnesium sulfate is administered for fetal neuroprotection in clients at <32 weeks gestation."

Correct Answers: A, B, and E Preterm labor (PTL) is defined as progressive, cervical dilation and/or effacement resulting from uterine contractions before 37 weeks gestation. The nurse should anticipate the following interventions for clients in PTL who are at <34 weeks gestation: · Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs · Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development · Initiating an IV magnesium sulfate infusion for fetal neuroprotection in clients who are at <32 weeks gestation · Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows time for antenatal glucocorticoids to have a therapeutic effect Incorrect Answers [C. "Clients in preterm labor require auscultation of fetal heart tones once per shift."] Clients with suspected PTL should be placed on continuous fetal monitoring to check for increasing frequency and duration of contractions and to evaluate fetal tolerance of labor. Continuous fetal monitoring is also required if the client is receiving a magnesium sulfate infusion. [D. "I will have equipment ready to assist with artificial rupture of membranes."] The health care provider performs artificial rupture of membranes (AROM), or amniotomy, to augment labor or assess amniotic fluid in clients at term gestation. For clients in PTL, the goal is to prolong pregnancy if possible. Therefore, AROM is contraindicated. Educational objective:Preterm labor is defined as progressive, cervical dilation and/or effacement resulting from uterine contractions before term gestation (ie, 37 week gestation). The nurse should anticipate several interventions, including administration of antibiotics, IM antenatal glucocorticoids, and IV magnesium sulfate.

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply. A. Capillary glucose of 60 mg/dL (3.3 mmol/L) B. Holosystolic murmur auscultated at fourth intercostal space C. Respirations of 56 breaths per minute D. Single transverse crease across palm of the hand E. White papules on bridge of the nose

Correct Answers: A, C, and E During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal. A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels. Normal newborn respiratory rate is 30-60 breaths per minute. Breathing may be slightly irregular, diaphragmatic, and shallow. Milia (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks Incorrect Answers: [B. Holosystolic murmur auscultated at fourth intercostal space] A holosystolic murmur (heard during entire systole phase) at the left lower sternal border is a classic sign of a ventricular septal defect (VSD). Although abnormal, most small VSDs close spontaneously within the first 6 months of life. [D. Single transverse crease across palm of the hand] A single transverse crease extending across the palm of the hand is a classic sign of Down syndrome (an extra copy of chromosome 21). Other signs include small and low-set ears, flat nose bridge, protruding tongue, and hypotonia. Educational objective:Expected findings for a neonate at 1-3 hours postpartum include respirations between 30-60 breaths per minute, milia, and glucose levels <70-100 mg/dL (3.9-5.6 mmol/L) but ≥40 mg/dL (2.2 mmol/L).

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select all that apply. A. Ask the parents if they would like to help bathe the infant B. Discourage the parents from naming the infant C. Discuss the importance of organ donation with the parents D. Encourage the parents and family members to hold the infant E. Offer to obtain handprints, footprints, and photographs of the infant

Correct Answers: A, D, and E Intrauterine fetal demise, or stillbirth, is the birth of an infant who is not alive. The nurse can assist with the perinatal bereavement process by using therapeutic communication, encouraging the parents and family to hold the infant, and providing privacy. Parents and family members may wish to help bathe and dress the infant, and should be encouraged to view and hold the body before discharge to the funeral home. The nurse should offer to obtain handprints and footprints, cut a lock of the infant's hair, and photograph the infant. These keepsakes are often precious mementos for grieving families who must leave the hospital without a child. However, none of these actions should be forced if the parents decline. Incorrect Answers: [B. Discourage the parents from naming the infant] The nurse should encourage family members to name the infant, which helps them identify the child as part of the family. The staff should refer to the infant by name during care. [C. Discuss the importance of organ donation with the parents] The nurse or primary health care provider should call the designated organ procurement organization, according to facility protocol. Discussions surrounding organ donation are best performed by trained personnel. Educational objective:Intrauterine fetal demise (ie, stillbirth) is the birth of an infant who is not alive. The nurse should encourage family members to hold and name the infant. Mementos (eg, hand/foot prints, photographs) should be made for the family to keep. However, none of these actions should be forced if the parents decline.

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply. A. Irritability and restlessness B. Meconium ileus and floppy muscle tone C. Microcephaly and cleft palate D. Nasal congestion and frequent sneezing E. Poor feeding and loose stools

Correct Answers: A, D, and E Neonatal abstinence syndrome (NAS) or opioid withdrawal results from maternal, habitual use of illicit drugs during pregnancy and begins within days or weeks after birth. Opioid abuse (eg, hydrocodone, methadone, heroin) is the most common cause, although other medications (eg, benzodiazepines) can contribute to the condition. Some affected newborns require pharmacologic management of symptoms. Clinical manifestations of NAS may be: · Central nervous system findings (eg, irritability, restlessness, high-pitched crying, abnormal sleep pattern, increased muscle tone, hyperactive primitive reflexes), which may require interventions such as swaddling and minimizing stimulation · Related to the autonomic nervous system (eg, nasal congestion, sweating, frequent yawning, sneezing, tachypnea) · Gastrointestinal (eg, poor feeding, vomiting, diarrhea), which may require smaller, more frequent feedings and skin protection Incorrect Answers [B. Meconium ileus and floppy muscle tone] Meconium ileus (ie, intestinal obstruction) is a classic finding in clients with cystic fibrosis. Floppy muscle tone is typical of clients with Trisomy 21 (Down syndrome). [D. Nasal congestion and frequent sneezing] Microcephaly and cleft palate are manifestations of early prenatal exposure to teratogenic agents (eg, alcohol, cytomegalovirus, valproic acid) and are not associated with NAS. Limited evidence has shown that opioids are generally not teratogenic. Educational objective:Prenatal exposure to illicit drugs may result in neonatal abstinence syndrome. A history of opioid abuse is the most common cause. Manifestations may include irritability, restlessness, a high-pitched cry, nasal congestion, frequent yawning/sneezing, poor feeding, and diarrhea.

A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of wine on weekends. BMI is 32 kg/m^2. Which teachings should the nurse reinforce as part of proper preconception health care for this client? Select all that apply. A. Avoid eating undercooked hamburgers B. Do not have more than 1 alcoholic drink per week C. Maintain current BMI D. Receive a rubella vaccine at least 3 months before attempting pregnancy E. Take 0.4 mg folic acid supplementation daily

Correct Answers: A, D, and E Preconception health care includes assessing for risk factors and implementing interventions (as appropriate) that will have a positive impact on a woman's health and future pregnancies. Interventions include the following: 1. Folic acid supplementation to reduce the incidence of neural tube defects: The beneficial impact of folic acid supplementation is greatest between 1 month before pregnancy and the end of the first trimester, the period of neural tube development. 2. Abstaining from alcohol and illicit drugs 3. Smoking cessation to prevent miscarriage and fetal growth retardation 4. Maintaining up-to-date vaccinations: Significant birth defects can occur if an unvaccinated mother is exposed to the rubella virus during pregnancy. To prevent these complications, the rubella vaccine should be given at least 3 months before attempting a pregnancy. 5. Avoiding contact with raw/undercooked meats, cat feces, and unpasteurized foods: Toxoplasma is a protozoan parasite found in cat feces and uncooked or rare beef and lamb. Toxoplasmosis can cause intellectual disability, blindness, or fetal demise when the embryo is exposed. Incorrect Answers: [B. Do not have more than 1 alcoholic drink per week] Consumption of any alcohol in pregnancy is not known to be safe; complete abstinence is recommended. [C. Maintain current BMI] Achieving a normal BMI (18.5-24.9 kg/m2) will reduce risk for fetal and maternal complications. Being underweight before pregnancy increases the risk for poor fetal growth and low birth weight. Obesity (BMI >30 kg/m2) is associated with subfertility, gestational diabetes, hypertension, and large-for-gestational-age birth weight. Educational objective:Preconception care involves folic acid supplementation; maintaining a normal weight (BMI 18.5-24.9); receiving any missed vaccinations; abstaining from tobacco, alcohol, and illicit drugs; and avoiding contact with raw or undercooked meats.

A nurse is reinforcing teaching to a breastfeeding client who has been diagnosed with mastitis of the right breast. Which instructions should be included? Select all that apply. A. Cease breastfeeding from right breast B. Increase oral fluid intake C. Reduce frequency of feeds to every 8 hours in right breast D. Take ibuprofen as needed for pain E. Use underwire bra 24 hours a day for support

Correct Answers: B and D Mastitis is a common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage (eg, poor latch). Bacteria are transmitted from the infant's nasopharynx or the mother's skin through the nipple and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema). In addition to antistaphylococcal antibiotics (dicloxacillin or cephalexin) and analgesics (eg, ibuprofen), treatment of lactational mastitis requires effective and frequent milk drainage. Milk ducts are most efficiently drained by direct breastfeeding while ensuring a proper latch. Adequate rest and increased oral fluid intake are also recommended. Incorrect Answers: [A. Cease breastfeeding from right breast] Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mothers should be reassured that the infant can feed safely from the infected breast as the newborn is already colonized with the mother's skin flora. [C. Reduce frequency of feeds to every 8 hours in right breast] Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mothers should be reassured that the infant can feed safely from the infected breast as the newborn is already colonized with the mother's skin flora. [E. Use underwire bra 24 hours a day for support] Underwire bras (tight bras) are not recommended with breastfeeding or mastitis as milk flow is impeded, worsening engorgement. Soft cup bras are recommended for support and to encourage milk flow. Educational objective:Treatment of lactational mastitis includes antibiotic therapy, breast support, adequate hydration, analgesics, and frequent (every 2-3 hours) continued breastfeeding.

A nurse is reinforcing information on formula preparation for a client with a newborn. Which statements by the client indicate proper understanding? Select all that apply. A. "I can add water to the formula if my baby wants to eat more frequently." B. "I must wash the top of the concentrated formula can before opening it." C. "I shouldn't heat formula in the microwave for more than 1 minute." D. "If my baby does not finish the bottle, the leftover milk should be refrigerated." E. "Prepared formula should be kept in the refrigerator and discarded after 48 hours."

Correct Answers: B and E Infant formula is readily available in 3 forms: ready-to-feed, concentrated, and powder. Parents who feed their infants commercial formula should closely follow the manufacturer's recommendations for preparation, particularly if the product requires dilution or reconstitution. Parents should also adhere to basic guidelines for safe storage and handling. Key teaching points include: · Keep bottles, nipples, caps, and other parts as clean as possible, either by boiling or washing in the dishwasher. · Wash the tops of formula cans prior to opening to prevent contamination. · Refrigerate prepared formula or opened cans of ready-to-feed or concentrated formula and discard after 48 hours if unused. There is a risk of bacterial growth after this time. · Warm prepared bottles by placing in a pan of hot water for several minutes. · Never microwave formula as it can cause mouth burns. · Test temperature on the inner wrist before serving to the infant; the formula should feel lukewarm, but never hot. Incorrect Answers: [A. "I can add water to the formula if my baby wants to eat more frequently."] Formula should never be diluted or concentrated. Dilution of the formula does not allow the infant to receive the appropriate amount of calories, vitamins, and minerals needed for normal growth and development. Overconcentration of the formula can cause excessive proteins and minerals to be ingested that exceed the excretory ability of the infant's immature kidneys. [D. "If my baby does not finish the bottle, the leftover milk should be refrigerated."] Any formula left in a bottle after a feeding should be discarded immediately because the infant's saliva has mixed with it, which encourages bacterial growth. Educational objective:Parents who feed their infants commercial formula should follow the manufacturer's recommendations for preparation and storage. For infant safety, formula should never be diluted, concentrated, or microwaved. After preparation, unused prepared formula can be stored in the refrigerator for up to 48 hours.

The nurse is reinforcing instructions to a client at 34 weeks gestation who is preparing to travel by airplane. Which of the following instructions are appropriate? Select all that apply. A. Avoid getting up during the flight unless you need the restroom B. Carry a copy of your most up-to-date prenatal record C. Increase fluid intake before and during the flight D. Secure the lap belt below the abdomen and across your hips when seated E. Wear compression hose and loose-fitting clothing

Correct Answers: B, C, D, and E Travel during pregnancy requires special modifications and precautions to ensure client safety and reduce the potential for injury and pregnancy complications. Clients should get their health care provider's approval prior to traveling long distances. Domestic air travel is usually allowed for healthy clients at <36 weeks gestation. When reinforcing education about travel safety, the nurse should instruct the client to: · carry an updated copy of the prenatal record in case emergency medical care is necessary during travel. · increase fluid intake to prevent dehydration and reduce the risk of thrombus formation or preterm contractions. · secure the lap belt under the gravid abdomen and across the hips and, if available, place shoulder belts lateral to the uterus and between the breasts to prevent complications from abdominal trauma (eg, placental abruption). · wear compression stockings and unrestrictive clothing to improve venous return and decrease the risk of thrombus formation. · avoid traveling to Zika- or malaria-prevalent areas and remote areas with poor medical care or lack of sanitation. Incorrect Answer [A. Avoid getting up during the flight unless you need the restroom] Pregnancy is a hypercoagulable state that augments the risk of thrombus formation. The nurse should encourage pregnant clients who embark on long travel to walk every 1-2 hours to decrease the risk of thrombus formation. Educational objective:When education about travel safety to pregnant clients is reinforced, recommendations should include carrying the prenatal record; increasing fluid intake; wearing compression stockings and loose clothing; avoiding long periods of sitting; and wearing the lap belt underneath the gravid abdomen and across the hips.

A practical nurse is collaborating with the registered nurse to form a care plan for a client diagnosed with placenta previa at 33 weeks gestation. What does the nurse anticipate being included in the plan of care? Select all that apply. A. Activity as tolerated B. Nonstress test 1 or 2 times a week C. Prepare for cesarean birth at any time D. Type and screen blood E. Vaginal examinations twice weekly

Correct Answers: B, C, and D In placenta previa, the placenta is implanted over or very near the cervix. As a result, placental blood vessels may be disrupted during dilation and effacement. Because of the increased risk of hemorrhage, the client should have a type and screen on file at the selected hospital. A nonstress test or biophysical profile should be performed once or twice a week to ensure fetal well-being. With asymptomatic clients, a cesarean birth is planned after 36 weeks gestation and prior to the onset of labor to prevent blood loss of mother and fetus. However, if the client is bleeding profusely or constantly or goes into active labor, a cesarean birth is typically performed immediately. Incorrect Answers: [A. Activity as tolerated] The recommended activity for a client at less than 36 weeks gestation with diagnosed placenta previa is bed rest with bathroom privileges. A stable client may be released to continue bed rest at home, but the client must be closely monitored and return to the hospital immediately if bleeding occurs. [E. Vaginal examinations twice weekly] Clients with placenta previa are placed on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of hemorrhage. Educational objective:Clients with placenta previa are at risk for hemorrhage. Bed rest with bathroom privileges is recommended for clients at less than 36 weeks gestation. A nonstress test or biophysical profile should be performed once or twice a week to evaluate fetal well-being. Pelvic rest is instituted to prevent disruption of the cervix. A cesarean birth is planned prior to onset of labor.

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply. A. Angle bottle up and toward the cleft B. Burping the infant often C. Feeding in an upright position D. Feeding slowly over 45 minutes or more E. Using a specialty bottle or nipple

Correct Answers: B, C, and E A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: · Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration. · Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. · Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing. · These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation. · Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. · Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. Incorrect Answer: [A. Angle bottle up and toward the cleft] Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. [D. Feeding slowly over 45 minutes or more] Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth. Educational objective:Children with cleft palates are at increased risk for inadequate intake as well as aspiration. Actions to promote intake and reduce aspiration risk include feeding in an upright position, pointing the nipple away from cleft, feeding over no more than 20-30 minutes, using special nipples or bottles, and feeding every 3-4 hours. The infant should be burped at regular intervals to reduce gastric distension.

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. A. One artery and one vein in the umbilical cord B. Plantar creases up the entire sole C. Skin on the nose blanches to a yellowish hue D. Toes fan outward when the lateral sole surface is stroked E. White pearl-like cysts on gum margins

Correct Answers: B, D, and E The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. Incorrect Answers: [A. One artery and one vein in the umbilical cord] The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks. [C. Skin on the nose blanches to a yellowish hue] Jaundice is best assessed in natural lighting, with gentle pressure to the skin over a firm surface such as the nose, forehead, or sternum. It first appears on the face and extends to the trunk and eventually the entire body. Jaundice within the first 24 hours is pathological. It is usually related to problems of the liver. Jaundice after 24 hours is referred to as physiological jaundice and is related to the increased amount of unconjugated bilirubin in the system. Educational objective:Expected (normal) findings for a term newborn include plantar creases up the sole of the foot, presence of Babinski reflex, and Epstein's pearls.

The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer? Temp 100.9 F (38.3 C) Blood pressure: 125/75 mm HgHR Pulse: 109/minRR Respirations: 15/min SpO2 100% A. Acetaminophen PO PRN for fever B. Clindamycin IV every 8 hours C. Lactated Ringer IV bolus once D. Methylergonovine PO every 4 hours

Correct Answers: B. Clindamycin IV every 8 hours Postpartum endometritis occurs when the endometrium (uterine lining) becomes infected after birth, often beginning at the placental site. Endometritis is characterized by uterine tenderness and subinvolution, foul-smelling or purulent lochia, fever, tachycardia, and chills. Cesarean birth is a primary risk factor, particularly if performed emergently or after prolonged labor. The infection is usually polymicrobial and requires treatment with broad-spectrum antibiotics (eg, IV clindamycin plus IV gentamicin). Antibiotic administration is a priority because it treats the primary cause of endometritis and prevents complications related to the spread of infection (eg, abscess, peritonitis). Antibiotics are required until approximately 24 hours after symptoms resolve. Incorrect Answers: [A. Acetaminophen PO PRN for fever] Antipyretics (eg, acetaminophen) and other comfort measures (eg, repositioning, oral hydration, pain medication) can be provided after antibiotic therapy is initiated. [C. Lactated Ringer IV bolus once] IV fluid administration (eg, Lactated Ringer IV bolus) is a supportive measure used to help resolve tachycardia and promote adequate hydration, but it does not take priority over antibiotic administration. [D. Methylergonovine PO every 4 hours] To promote uterine involution, uterotonics (eg, PO methylergonovine) may be prescribed. Although uterine involution can promote drainage of purulent lochia, methylergonovine does not take priority over antibiotics, which are needed to treat the cause of infection. Educational objective:Postpartum endometritis is an infection of the endometrium (uterine lining) and is characterized by fever, chills, tachycardia, uterine tenderness, and foul-smelling or purulent lochia. The nurse's priority intervention is initiation of broad-spectrum antibiotics to treat the infection and reduce the risk of complications (eg, abscess, peritonitis). Subsequent interventions include antipyretics, IV fluids, and (possibly) uterotonics for uterine subinvolution.

The nurse is observing a pregnant client receiving an oxytocin infusion for induction of labor. The baseline fetal heart rate is 140/min; the strip is shown in the exhibit. What is the nurse's best course of action? [Exhibit: a fetal heart rate strip depicting Moderate Variability] A. Apply oxygen 10 L/min by facemask B. Continue to monitor the client C. Discontinue oxytocin infusion D. Notify the registered nurse

Correct Answers: B. Continue to monitor the client The fetal heart rate strip shows 2 accelerations and moderate variability. An acceleration of the fetal heart rate of at least 15/min above the baseline lasting for at least 15 seconds is a reassuring finding most often indicating fetal movement. Moderate variability refers to fluctuations in the baseline heart rate between 6-25/min. It is considered normal and indicates that the fetus is healthy and has adequate oxygenation and normal function of the autonomic nervous system. No immediate intervention is needed. Incorrect Answers: [A. Apply oxygen 10 L/min by facemask] A nonreassuring heart rate pattern such as late or variable decelerations would require the need to stop oxytocin, apply oxygen, and notify the registered nurse or health care provider. [C. Discontinue oxytocin infusion] A nonreassuring heart rate pattern such as late or variable decelerations would require the need to stop oxytocin, apply oxygen, and notify the registered nurse or health care provider. [D. Notify the registered nurse] A nonreassuring heart rate pattern such as late or variable decelerations would require the need to stop oxytocin, apply oxygen, and notify the registered nurse or health care provider. Educational objective:An acceleration is a reassuring finding most often indicating fetal movement. Moderate variability is considered "good" and "normal" and fluctuates off baseline from 6-25/min.

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply. A. Avoid intake of dairy products B. Drink large amounts of fluid with meals C. Eat several small meals each day D. Eliminate fried, fatty foods E. Lie down on the left side after meals

Correct Answers: C and D Pyrosis, or heartburn, is common during pregnancy due to an increase of the progesterone hormone and uterine enlargement that displaces the stomach. Progesterone relaxes smooth muscles, resulting in esophageal sphincter relaxation. Gastric contents are then regurgitated, usually causing a burning sensation behind the sternum. The nurse should educate the client about lifestyle changes for reducing heartburn, such as: · Keep the head of the bed elevated using pillows · Sit upright after meals · Eat small, frequent meals · Avoid tight-fitting clothing · Eliminate common dietary triggers (eg, fried/fatty foods, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated drinks, peppermint) Incorrect Answers: [A. Avoid intake of dairy products] Dairy products do not typically lead to heartburn and are an important source of calcium during pregnancy. [B. Drink large amounts of fluid with meals] The client can minimize gastric distension, gastric acid production, and subsequent reflux by drinking small amounts of fluid while eating and avoiding overeating. The client should be instructed to cluster fluid intake between meals instead. [E. Lie down on the left side after meals] Lying down immediately after eating exacerbates reflux and may lead to more discomfort. Educational objective:Pyrosis is common during pregnancy due to an increase of the progesterone hormone, which causes the esophageal sphincter to relax. Lifestyle changes to reduce symptoms include eating smaller meals, avoiding trigger foods (eg, fried/fatty food), maintaining an upright position after meals, and drinking fluids mostly between meals.

The practical nurse (PN) is assisting the registered nurse (RN) to care for a client receiving oxytocin for induction of labor. Which of the following actions by the PN are appropriate during oxytocin infusion? Select all that apply. A. Assess deep tendon reflexes every hour B. Assist RN to initiate intermittent fetal monitoring C. Evaluate fluid intake and output every 4 hours D. Notify RN if >5 contractions occur in 10 minutes E. Obtain blood pressure with each oxytocin dose change

Correct Answers: C, D, and E Oxytocin is a high-alert medication commonly used for labor induction or augmentation. Oxytocin is titrated by the registered nurse (RN) on an infusion pump to achieve an adequate contraction pattern (eg, contractions every 2-3 min). If >5 contractions occur in 10 minutes (ie, uterine tachysystole), the practical nurse (PN) should notify the RN immediately to decrease the infusion rate. Uterine tachysystole can cause decreased placental perfusion, a nonreassuring fetal heart rate (FHR), or uterine rupture. Water intoxication is a potential complication of oxytocin administration that causes dilutional hyponatremia, convulsions, and death. Therefore, the PN should monitor fluid intake and output every 4 hours to identify fluid retention, which is an early sign of water intoxication. Hypotension can occur with rapid oxytocin bolus; therefore, blood pressure, heart rate, and respirations are assessed every 30 minutes or with each oxytocin dose change to identify changes from baseline. Incorrect Answers: [A. Assess deep tendon reflexes every hour] Regular assessment of deep tendon reflexes is necessary for clients receiving magnesium sulfate, which causes central nervous system depression. [B. Assist RN to initiate intermittent fetal monitoring] The PN should anticipate continuous, not intermittent, electronic FHR and contraction monitoring for clients receiving oxytocin because of the potential for uterine tachysystole and abnormal FHR patterns. Educational objective:Oxytocin is a high-alert medication for labor induction requiring frequent maternal/fetal assessment (eg, fetal heart rate, contraction pattern, vital signs, fluid intake and output). Oxytocin infusion can cause maternal water intoxication, hypotension, uterine tachysystole, and a nonreassuring fetal heart rate.

A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation? A. "I feel so exhausted that I started taking naps when the baby sleeps." B. "I have trouble sleeping well at night because I worry that I won't hear the baby cry." C. "My aunt has come over every day to care for the baby because the baby's cries bother me." D. "My spouse thinks that I have been more emotional since I had the baby last week."

Correct Answers: C. "My aunt has come over every day to care for the baby because the baby's cries bother me." Perinatal mood disorders may occur at any time during pregnancy but are often precipitated in the postpartum period by the sudden drop in estrogen and progesterone levels after birth. Clients with postpartum depression may feel intense and persistent irritability, anxiety, anger, guilt, and sadness. Such feelings may affect the ability to care for the newborn or themselves. A client showing irritability and disinterest in caring for the newborn should be further assessed for postpartum depression and offered a referral for follow-up care. Incorrect Answers: [A. "I feel so exhausted that I started taking naps when the baby sleeps."] Maternal fatigue or decreased energy is common after birth and while caring for a newborn. The nurse can reassure the client that sleeping when the newborn sleeps is a good strategy as normal newborn sleep and feeding habits may require the client's attention frequently day and night. [B. "I have trouble sleeping well at night because I worry that I won't hear the baby cry."] Postpartum blues ("baby blues") is a common, milder form of depression characterized by emotional lability, sadness, anxiety, and difficulty sleeping. However, the client's ability to function properly is not affected, and symptoms subside within 2 weeks without treatment. If symptoms persist after 2 weeks, further assessment may be necessary. [D. "My spouse thinks that I have been more emotional since I had the baby last week."] Postpartum blues ("baby blues") is a common, milder form of depression characterized by emotional lability, sadness, anxiety, and difficulty sleeping. However, the client's ability to function properly is not affected, and symptoms subside within 2 weeks without treatment. If symptoms persist after 2 weeks, further assessment may be necessary. Educational objective:Perinatal mood disorders may occur at any time during pregnancy but are more common in the immediate postpartum period. Clients with postpartum depression may feel intense and persistent anxiety, anger, guilt, and sadness. A client showing irritability and disinterest in caring for the newborn should be assessed for postpartum depression and offered a referral for follow-up care.

A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first? A. Administer 10 units oxytocin IM B. Apply oxygen via nonrebreather facemask at 10 L/min C. Assist the client to void on a bedpan D. Draw blood for a hemoglobin and hematocrit level

Correct Answers: C. Assist the client to void on a bedpan Postpartum vaginal bleeding that saturates a perineal pad in <1 hour is considered excessive. Furthermore, a boggy fundus indicates uterine atony. A fundus elevated above the umbilicus and deviated to the right suggests a distended bladder. Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous placental site. The client should be assisted to void to correct bladder distension. The nurse should then perform fundal massage and reevaluate bleeding. Incorrect Answers: [A. Administer 10 units oxytocin IM] Oxytocin (Pitocin) stimulates uterine contraction, which compresses blood vessels at the previous placental implantation site. Oxytocin may be given IM if initial attempts to control postpartum bleeding (eg, relief of bladder distension, fundal massage) fail and the client has no working IV line. [B. Apply oxygen via nonrebreather facemask at 10 L/min] Oxygen delivery at 10 L/min via a nonrebreather facemask may be initiated if the client becomes symptomatic following excessive blood loss. However, the first priority is to control the bleeding. [D. Draw blood for a hemoglobin and hematocrit level] Blood tests to determine hemoglobin and hematocrit levels may be needed following excessive postpartum bleeding. However, this intervention does not correct the immediate problem of uterine atony related to bladder distension. Educational objective:Excessive postpartum bleeding is commonly caused by uterine atony. If the nurse suspects uterine atony is caused by bladder distension (ie, boggy fundus, fundus above the umbilicus and deviated to the right) the client should first be assisted to void; fundal massage and oxytocin should follow as needed to control the bleeding.

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up? A. Edema of the scalp crossing the suture lines B. Flat, bluish, discolored area on the buttocks C. Small tuft of hair at the base of the spine D. White, waxy substance in the axillae and labial folds

Correct Answers: C. Small tuft of hair at the base of the spine Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially allows spinal cord contents to protrude through the opening. The mildest form is spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss) of varying severity. Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of the spine. The nurse should notify the health care provider because further assessment and surgical repair may be required. Incorrect Answers: [A. Edema of the scalp crossing the suture lines] Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to prolonged pressure of the presenting part against the cervix during labor, resolves in a few days. [B. Flat, bluish, discolored area on the buttocks] Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal melanocytosis (ie, Mongolian spots). [D. White, waxy substance in the axillae and labial folds] Vernix caseosa, a protective substance covering the fetus, is secreted by the sebaceous glands. This white, cheesy/waxy substance is most likely seen in the axillary and genital areas of term newborns. Educational objective:Spina bifida is a neural tube defect that occurs when spinal vertebrae do not close during fetal development, potentially allowing spinal cord contents to protrude through the opening. A tuft of hair, hemangioma, nevus, or dimple at the base of the spine may indicate the mildest form, spina bifida occulta.

The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk has a pink color. What is the nurse's initial action? A. Apply oxygen and count respirations B. Assess heart sounds for a murmur C. Observe for expiratory grunting D. Place infant skin-to-skin with mother

Correct Answers: D. Place infant skin-to-skin with mother Acrocyanosis is peripheral cyanosis that is considered normal during the first day of life or up to 7-10 days after birth if the infant becomes cold. It manifests as a bluish discoloration of the hands and feet and sometimes the skin around the mouth. It results from poor perfusion of blood to the periphery of the body as an initial mechanism to reduce heat loss and stabilize temperature. Initial nursing management is to keep the newborn warm by placing skin-to-skin with the mother or under a radiant warmer. The nurse should also frequently assess axillary temperature to ensure that the newborn is properly retaining body heat. Stable body temperature is generally reached within 6-12 hours after birth. However, if peripheral cyanosis is present with central cyanosis of the mucous membranes or trunk, along with signs of grunting, nasal flaring, retractions, or an abnormal breathing rate (<30 or >60/min), the infant may be experiencing respiratory distress and requires immediate further assessment and intervention. Incorrect Answers: [A. Apply oxygen and count respirations] Acrocyanosis is considered normal during the first day, so supplemental oxygen is not warranted. [B. Assess heart sounds for a murmur] Expiratory grunting and cardiac murmurs are signs of potential cardiac or respiratory abnormalities. Transient acrocyanosis without central cyanosis in the first day of life is considered normal and not indicative of a pathologic condition. [C. Observe for expiratory grunting] Expiratory grunting and cardiac murmurs are signs of potential cardiac or respiratory abnormalities. Transient acrocyanosis without central cyanosis in the first day of life is considered normal and not indicative of a pathologic condition. Educational objective:Acrocyanosis manifests as bluish coloration of the hands and feet in the newborn and is considered a normal finding during the first day of life or if the newborn becomes cold. Initial nursing management is to keep the infant warm by placing skin-to-skin with the mother or under a radiant warmer.

The nurse is reinforcing discharge instructions to a postpartum client. Which instruction should the nurse include to promote newborn safety? A. Avoid using blankets to position the infant in the car seat B. Place the infant in the prone position in bed while sleeping C. Position the infant's car seat in the back seat facing forward D. Remove pillows and loose blankets from the infant's crib

Correct Answers: D. Remove pillows and loose blankets from the infant's crib Basic principles of newborn safety, particularly those related to proper car seat use and safe sleep practices, should be reinforced in postpartum discharge instructions. Proper car seat use instructions include the following: · Infants should be placed in a federally-approved, rear-facing safety seat that is secured in the back seat of the car. · The harness should be snug, with the retaining clip secured near the level of the armpits. If the newborn is preterm or small, rolled blankets or car seat inserts (on both sides and under the crotch level buckles) may be used to support the trunk and reduce slouching. · Infants should be positioned at a 45-degree angle to prevent airway obstruction. Safe-sleep practices include the following: · The supine position is recommended for infants in the first few months of life. This practice is associated with a lower incidence of sudden infant death syndrome. · Infants should sleep in the crib wearing clothing such as a sleep sack. This lowers the risk of suffocation by keeping the infant warm while preventing the head from being covered. · Parents should remove loose bedding and other objects (eg, blankets, bumper pads, stuffed animals, pillows) from the crib to reduce the risk of suffocation. · Crib slats should be no more than 2¼ inches apart to prevent the infant's head from becoming lodged between them. Educational objective:Infants should be placed in a rear-facing safety seat secured in the back seat of the car. The supine position is recommended for infants to decrease the risk of sudden infant death syndrome. Infant sleep sacks keep the infant warm while preventing the head from becoming covered.