OB Exam 2

Mastitis as an inflammation of the _____.

Breast Mastitis is an inflammation or infection of the breast. This can occur when bacteria enter the breast through cracks around the nipple area.

The perinatal nurse knows that the survival rate for infants born at or greater than 28 to 29 gestationalweeks is greater than 90%. T/F

True With appropriate medical care, neonatal survival dramatically improves as the gestational age increases, with over 50% of neonates surviving at 25 weeks gestation, and over 90% surviving at 28 to 29 weeks of gestation.

A pregnancy that ends before 20 weeks gestation

miscarriage

When assessing a newborn for coagulation factors, the perinatal nurse recalls that coagulation factors to enable the newborn to effectively clot blood after childbirth are activated by _________.

vitamin K

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal problems could have resulted in this complication? (Select all that apply.) a. Cholecystitis b. Hypertension c. Cigarette smoker d. Candidiasis e. Cerebral palsy

b. Hypertension c. Cigarette smoker

A nurse is preparing a woman in early labor for an urgent cesarean birth related to breech presentation. Select the best nursing action for reducing the couples anxiety levels. a. Explain the reason for the need for a cesarean section. b. Inform parents that their baby is in distress. c. Ask the couple to share their concerns. d. Reassure the couple that both the woman and baby are in no danger.

c. Ask the couple to share their concerns.

No expulsion of the products of conception, but bleeding and dilation of the cervix such that a pregnancy is unlikely

Inevitable abortion

The perinatal nurse observes the placental inspection by the health-care provider after birth. This examination may help to determine whether an abruption has occurred prior to or during labor. T/F

True Fifty percent of abruptions occur before labor and after the 30th week, 15% occur during labor, and 30%are identified only upon inspection of the placenta after delivery.

It is a common custom for traditional Chinese women to bottle feed their infants until their milk comes in. T/F

True It is common for traditional Chinese women to bottle feed until their milk comes in.

A G2P1 woman who experienced a prolonged labor and prolonged rupture of membranes is at risk for metritis. Which of the following nursing actions are directed at decreasing this risk? (SATA) a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls 4 times a day d. Instruct woman to apply ice packs to the perineum

a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls 4 times a day

A healthy, full-term baby is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Obtain the neonate's protime.

a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure.

Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is: a. Teaching proper techniques for latching-on and releasing of suction b. Applying hot compresses to breast prior to feeding c. Instructing woman to express colostrum or milk at the end of the feeding session and rub it on her nipples d. Air drying nipples for 10 minutes at the end of the feeding session

a. Teaching proper techniques for latching-on and releasing of suction

A 16 yo woman delivers a healthy, full-term male infant. The nurse notes the following behaviors 2 hours after birth: woman holds baby away from her body; woman refers to baby as he; woman verbalizes she wanted a baby girl; woman requests that the baby be placed in the bassinet so she can eat her lunch. The most appropriate nursing diagnosis for this woman is: a. risk for impaired parenting related to disappointment with baby as evidenced by verbalizing she wanted a girl b. risk for impaired parenting related to nonnurturing behaviors as evidenced by holding baby away from body c. risk for impaired mother infant attachment as evidenced by woman requesting baby being placed in bassinet d. risk for impaired mother infant attachment related to disappointment as evidenced by calling baby he

a. risk for impaired parenting related to disappointment with baby as evidenced by verbalizing she wanted a girl

A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.

b. Bathe and weigh a 3-hour-old baby.

The nurse is developing a discharge teaching plan for a 21-year-old first- time mom. This was an unplanned pregnancy. She had a prolonged labor and an early postpartum hemorrhage. The woman plans to breastfeed her baby. She plans to return to work when her baby is 3 months old. Based on this information, the three primary learning needs of this woman are: a. Breastfeeding, bathing of the newborn, and infant safety b. Breastfeeding, storage of milk, and nutrition c. Breastfeeding, contraception, infant safety d. Breastfeeding, storage of milk, and rest

b. Breastfeeding, storage of milk, and nutrition

During change of shift report, the nurse hears the following information on a newly delivered client: 27 yo, married, G4 P3, 8 hours post spontaneous vaginal delivery with 3rd degree laceration. Vitals 110/70, 98.6F, 82, 18, fundus firm at umbilicus, moderate lochia, ambulated to bathroom to void 3 times for a total of 900mL, breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this clients nursing care plan? a. Fluid volume deficit b. Impaired skin integrity c. Impaired urinary elimination d. Ineffective breastfeeding

b. Impaired skin integrity

Which of the following nursing actions are important in the care of a postpartum woman who is at risk for orthostatic hypotension? (SATA) a. Have the patient remain in bed for the first 4 hours post birth b. Instruct patient to slowly rise to a standing position c. Open an ammonia ampule and have the patient smell the ammonia prior to getting out of bed d. Explain to the patient the cause and incidence of orthostatic hypotension

b. Instruct patient to slowly rise to a standing position d. Explain to the patient the cause and incidence of orthostatic hypotension

A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is: a. Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system? b. The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections? c. Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health? d. I see that this is very upsetting for you. I will come back later and answer your questions.

c. Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health?

The labor patient you are caring for is ambulating in the hall. Her vaginal exam 1 hour ago indicated she was 4/70/1 station. She tells you she has fluid running down her leg. Your priority nursing intervention is to: a. Assess the color, odor, and amount of fluid. b. Assist your patient to the bathroom. c. Assess the fetal heart rate. d. Call the care provider.

c. Assess the fetal heart rate.

The nurse is caring for a woman, G2 P1001, 40 weeks' gestation, in labor. A 12 P.M. assessment revealed: cervix 4 cm, 80% effaced, -3 station, and fetal heart 124 with moderate variability. 5 p.m. assessment: cervix 6 cm, 90% effaced, -3 station, and fetal heart 120with minimal variability. 10 a.m. assessment: cervix 8 cm, 100% effaced, -3 station, and fetal heart 124with absent variability. Based on the assessments, which of the following should the nurse conclude? a. Descent is progressing well. b. Woman is carrying a small-for-gestational age fetus. c. Baby is potentially acidotic. d. Woman should begin to push with the next contraction.

c. Baby is potentially acidotic.

A nurse is providing discharge teaching to the parents of a 2-day-oldneonate. Which of the following information should be included in the discharge teaching on umbilical cord care? a. Cleanse the cord twice a day with hydrogen peroxide. b. Remove the cord with sterile tweezers if the cord does not fall off by 10 days of age. c. Call the doctor if greenish discharge appears. d. Cover the cord with sterile dressing until it falls off.

c. Call the doctor if greenish discharge appears.

The perinatal nurse is providing care to Carol, a 28-year-old multiparous woman in labor. Upon arrival to the birthing suite, Carol was 7 cm dilated and experiencing contractions every 1 to 2 minutes which she describes as ―strong.‖ Carol states she labored for 1 hour at home. As the nurse assists Carol from the assessment area to her labor and birth room, Carol states that she is feeling some rectal pressure. Carol is most likely experiencing: a. Hypertonic contractions b. Hypotonic contractions c. Precipitous labor d. Uterine hyperstimulation

c. Precipitous labor

A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly? a. The nurse measures the fundal height in relation to the symphysis pubis b. The nurse monitors the client's central venous pressure c. The nurse assesses the client's perineum for edema and ecchymoses d. The nurse performs a sterile vaginal speculum exam

c. The nurse assesses the client's perineum for edema and ecchymoses

When caring for a primiparous woman being evaluated for admission for labor, a key distinction between true versus false labor is: a. True labor contractions result in rupture of membranes, and with false labor, the membranes remain intact .b. True labor contractions result in increasing anxiety and discomfort and false labor does not. c. True labor contractions are accompanied by loss of the mucus plug and bloody show, and with false labor there is no vaginal discharge. d. True labor contractions bring about changes in cervical effacement and dilation, and with false labor there are irregular contractions with little or no cervical changes.

d. True labor contractions bring about changes in cervical effacement and dilation, and with false labor there are irregular contractions with little or no cervical changes.

A pregnant patient at 35 weeks' gestation gives birth to a healthy baby boy. What factors regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate? a. As the fetus approaches term, there is an increase in the secretion of intrapulmonary fluid. b. Lung expansion after birth suppresses the release of surfactant. c. Surfactant causes an increased surface tension within the alveoli, which allows for alveolar re-expansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability

d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability

The clinic nurse sees Xiao and her infant in the clinic for their 2 week follow up visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurses most appropriate question to ask would be: a. What has happened to you? b. Do you have help at home? c. Is there anything wrong with your son? d. Would you tell me about the first few days at home?

d. Would you tell me about the first few days at home?

The NICU nurse is providing care to a 35-week-old infant who has been in the neonatal intensive care unit for the past 3 weeks. His mother wants to breastfeed her son naturally but is currently pumping her breasts to obtain milk. His mother is concerned that she is only producing about 1 ounce of milk every 3 hours. The nurse's best response to the patient's mother would be: a. Pumping is hard work and you are doing very well. It is good to get about 1ounce of milk every 3 hours. b. Natural breastfeeding will be a challenging goal for your baby. Beginning today, you will need to begin to pump your breasts more often. c. Your baby will not be ready to go home for at least another week. You can begin to pump more often in the next few days in preparation for taking your child home. d. You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more often to prepare to take your baby home.

d. You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more often to prepare to take your baby home.

The perinatal nurse knows that the presence of abdominal distension and gas in the post cesarean birth mother is due to _________ ___________.

delayed peristalsis Delayed peristalsis and constipation commonly occur because of slowed peristalsis associated withpregnancy hormones and childbirth anesthesia. In addition, incisional pain may contribute to a decrease in ambulation which contributes to delayed peristalsis.

Mary, a G3 TPAL 0020 woman at 20 weeks gestation, has had a transvaginal ultrasound. Mary has been informed that she has cervical incompetence. The perinatal nurse explains that this diagnosis means that her cervix has _____ without ______ contractions.

dilated, regular Patients with cervical incompetence usually present with painless dilation and effacement of the cervix, often during the second trimester of pregnancy. The patient frequently gives a history of repeated secondtrimester losses with no apparent etiology. Incompetent cervix is estimated to cause approximately 15% of all second trimester losses.

The perinatal nurse prepares for two potential complications that may accompany a precipitous labor and birth: postpartum _______ and a need for neonatal _______

hemorrhage; resuscitation Complications from a precipitate labor pattern result from trauma to maternal tissue and to the fetus because of the rapid descent. Hemorrhage may occur from uterine rupture and vaginal lacerations. The fetus may suffer from hypoxia related to the decreased periods of uterine relaxation between the contractions and intracranial hemorrhage related to the rapid birth.

The perinatal nurse provides information about postpartum depression to all family members because of the potential danger not only to the mother but also to the _____.

infant

The perinatal nurse caring for a laboring woman who is receiving an oxytocin infusion documents the following information: rate of ________, frequency and strength of _________, fetal _______, and cervical _________and __________.

infusion; contractions; heart rate; dilation; effacement Oxytocin protocols in many institutions require that the nurse remain at the patient's bedside at all times for careful surveillance. The following data shouldbe placed on a flow sheet in the patient record: patient's vital signs, fetal heartrate, frequency, duration and strength of contractions, cervical effacement anddilatation, fetal station and lie, rate of oxytocin infusion intake and urine output, and the psychological response of the patient

During labor, oxytocin is always administered __________.

intravenously with an infusion pump During labor, oxytocin can only be administered intravenously via an infusion pump to titrate and regulate the dose for safe administration.

Providing information to parents about jaundice constitutes an important component of the nurse's discharge teaching. Ensuring that parents know when and who to call if their infant develops signs of jaundice will help decrease the risk of ________, or permanent brain damage.

kernicterus

A nurse assesses a G2P1 woman who gave birth to a 4500-gram baby boy 2 hours ago. The nurse notes that the womans labor was only 2 hours and that the infant was delivered by the labor nurse. The nurses assessment findings are: Fundus firm and midline at umbilicus; lochia heavy, saturates pad within 15 minutes and bleeding is a steady stream without clots; perineum intact, slight bruising; ice pack on perineum; vital signs are BP 105/65, P 98, RR 20, T 38. Based on this information, the nurse is concerned that the woman has a ________ of the _________ or _________.

laceration; cervix; vagina

The clinic nurse discusses gradual warming of expressed breast milk or formula and cautions against use of the ________ for heating breastmilk or formula.

microwave oven

Part of the assessment of a preterm infant includes obtaining an abdominal girth measurement. The NICU nurse performs this assessment because the patient is at risk for _____________.

necrotizing enterocolitis (NEC)

Upon assessment of the temperature of a newborn, the nurse recalls that the _________ is the range of temperature in which the newborn's body temperature can be maintained with minimal metabolic demands and oxygen consumption.

neutral thermal environment (NTE)

A condition where the placenta attaches to the lower uterine segment of the uterus

placenta previa

Postpartum women are at an increased risk of thrombus formation immediately following birth due to an increased ____________ level.

plasma fibrinogen

The NICU nurse recognizes that the infant who requires ventilation for meconium aspiration syndrome is most often _________.

post-term

The perinatal nurse understands that the hormonal processes involved in breastfeeding include decreased serum ________ and ________ levels immediately following birth which lead to an increased serum ______ level that causes milk production by the fourth to fifth postpartal days.

progesterone; estrogen; prolactin

A postpartum woman who describes symptoms of hallucinations and suicidal thoughts is most likely experiencing postpartum _____.

psychosis

The perinatal nurse encourages Colleen, who has just been discharged from the hospital for intravenous therapy for severe nausea and vomiting, to ensure that she ______ often, eats frequent, ______ meals, and avoids ______ odors.

rests, small, cooking The nurse should counsel the woman with nausea and vomiting to avoid foods and sensory stimuli that provoke symptoms (i.e., some women become nauseous when they smell certain foods being prepared) and also to eat small, frequent meals of dry, bland foods and include high-protein snacks in their diet.

The development of a large hematoma can place the postpartum woman at risk for _____.

shock

The Joint Commission Standard states that the __________, _________, and _________ are accurately identified and clearly communicated during the final verification process before the start of any surgical or invasive procedure.

site; procedure; patient To decrease the risk of surgery or invasive procedure being done on the wrong patient or in the wrongsite, a time-out is called, and active communication to verify correct procedure, site, and patient is done just prior to the beginning of surgery or invasive procedure.

The perinatal nurse encourages all mothers to place their infants under 12months of age in the supine position for sleeping, because a leading cause of death for this age group is ______.

sudden infant death syndrome (SIDS)

The perinatal nurse explains to a new mother that the first sign of a postpartum infection will most likely be an increased ______.

temperature

Primary breast engorgement is an increase in the __________ and __________ systems that precedes the initiation of milk production.

vascular; lymphatic Primary breast engorgement is an increase in the vascular and lymphatic systems that precedes the initiation of milk production. Subsequent breast engorgement is related to distention of milk glands.

The NICU nurse's patient assignment includes an infant who is 25 weeks' gestation. The nurse knows that according to the gestational age, this infant would be described as ___________.

very premature

A hematoma is the collection of blood beneath the intact skin layer following an injury to a blood vessel. T/F

True A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. At the time of injury, pressure necrosis and inadequate hemostasis occur.

Metritis is an infection that usually starts at the placental site. T/F

True Metritis is an infection of the endometrium that usually starts at the placental site and spreads to encompass the entire endometrium.

Which of the following positions for breastfeeding is preferred for a 2-daypostcesarean-birth woman? a. Lying down on side b. Sitting c. Cradle d. Cross-cradle

a. Lying down on side

A 37yo G8P7 woman was admitted to the postpartum unit at 2 hours postbirth. On admission to the unit, her fundus was U/U, midline and firm, and her lochia was moderate rubra. An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is: a. Massage fundus of the uterus b. Assist the woman to the bathroom and reassess the fundus c. Notify the physician or midwife d. Start IV oxytocin therapy as per standing orders

a. Massage fundus of the uterus

A 42-week gestation neonate is admitted to the NICU (neonatal intensive care unit). This neonate is at risk for which complication? a. Meconium aspiration syndrome b. Failure to thrive c. Necrotizing enterocolitis d. Intraventricular hemorrhage

a. Meconium aspiration syndrome

The nurse is aware that the ________ state, which generally occurs during the first 30 minutes to 1 hour after birth, characterizes the first period of reactivity and provides an excellent time for parents to bond with their infant.

quiet alert

The perinatal nurse knows that an early pregnancy loss occurs before ____ weeks, and a late pregnancy loss is one that occurs between 12 and ____ weeks.

12, 20 Not all conceptions result in a live-born infant. Of all clinically recognized pregnancies, 10% to 20% arelost, and approximately 22% of pregnancies detected on the basis of hCG assays are lost before the appearance of any clinical signs or symptoms. By definition, an early pregnancy loss occurs before 12 weeks of gestation; a late pregnancy loss is one that occurs between 12 and 20 weeks of gestation.

A post-cesarean section client has been ordered to receive 500 mL of 5% dextrose in water every 4 hours. The drop factor of the macrodrip tubing is 10 gtt/mL. To what drip rate should the nurse regulate the IV? _____ gtt/min

21 gtt/min

A newborn was born weighing 2576 grams. On day 2 of life, the babyweighed 2345 grams. What percentage of weight loss did the baby experience? (Calculate to the nearest hundredth.)

8.97% The neonate has lost 231 grams (2576 grams - 2345 grams = 231 grams).The percentage lost is 231 grams/2576 grams/100% = 8.97% weight loss.

The serosa stage of lochia usually occurs between day ____ and ____ and the lochia is a ____ or ____ color, and the amount is normally ____.

4; 10; pink; brown; scant

Match the term with the definition 56. Third stage of labor 57. Transition phase 58. False labor 59. Latent phase a. Early and slow labor. Can last up to 9 hours. Many women choose to stay home b. Irregular contractions, with no increase in frequency, intensity, and duration, cause little or no cervical change c. Cervical dilation from 8 to 10 cm, contractions every 1 to 2 minutes. Woman may be panicky and irritable. d. Occurs immediately after the delivery of the fetus. Involves the separation and delivery of the placenta. Can last up to 20 minutes.

56. d 57. c 58. b 59. a

The postpartum period is the first _________weeks following birth.

6 Postpartum is the 6-week period of time following childbirth. It is a time of rapid physiological changes within the woman's body as it returns to a prepregnant state.

The gray, blue, or purple areas on the buttocks of a neonate are referred to as __________.

Mongolian spots

As the nurse explains the purpose of the tocotransducer (Toco), which she places on the abdomen, she states that this monitoring device provides an accurate evaluation of which of the following? a. Uterine hypertonus b. Frequency of contractions c. Intensity of contractions d. Progress of labor

b. Frequency of contractions

Early decelerations are probably caused by: a. Decreased maternal-fetal exchange b. Umbilical cord occlusion c. Momentary increase in intracranial pressure due to head compression d. Compression of umbilical cord

c. Momentary increase in intracranial pressure due to head compression

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132

c. The baby with temperature 96.3°F, length 17 inches

A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.

d. Circumcision site oozes blood.

Specks or spots in the vision where the patient cannot see; blind spots

scotoma

Placement of suture to mechanically close a weak cervix

Cervical cerclage

Bonding is bidirectional from parent to infant and infant to parent. T/F

False Bonding unidirectional from parent to infant. Attachment is bidirectional.

The postpartum nurse is caring for a couple who experienced an unplanned emergency cesarean birth. The nurse observes the following behaviors: Parents are gently touching their newborn, mother softly singing to her baby, father is gazing into babys eyes. Based on this data, the correct nursing diagnosis is altered parent infant bonding related to emergency cesarean birth. T/F

False Cesarean birth can place the parents at risk for bonding, but based on the observed interaction with their newborn, the parents display positive signs of bonding.

It is critical for the perinatal nurse to learn, as part of the facilitys policies and procedures, to immediately perform a vaginal examination on a woman who presents with vaginal bleeding after 24weeks gestation. T/F

False Placenta previa should be suspected in all patients who present with bleeding after 24 completed weeks ofgestation. Because of the risk of placental perforation, vaginal examinations are not performed

During an emergency cesarean birth the time-out procedure may be omitted based on the obstetrical emergency. T/F

False Joint commission guidelines for patient safety necessitate there always be a time-out to preventwrong patient, wrong site, wrong procedure, and medical errors.

The clinic nurse recognizes that the longer an infant is formula fed, the greater is the immunity and resistance the infant will develop against bacterial and viral infections. T/F

False One of the primary benefits of breastfeeding, not formula feeding, is the decreased incidence of bacterial and viral infections as a result of passive immunity, including the transfer of maternal antibodies.

The perinatal nurse explains to the student nurse that the most frequent fetal risk associated with the use of forceps is cord compression. T/F

False The most frequent fetal risk associated with the use of forceps is superficial scalp or facial marks that will resolve quickly

A disease characterized by an abnormal placental development that results in the production of fluid-filled grapelike clusters and a vast proliferation of trophoblastic tissue

Hydatidiform mole/Gestational trophoblastic disease

________ is a vasomotor response to decreased body temperature afterbirth.

Mottling

When reviewing potential causes for postpartum hemorrhage with the student nurse, the nurse is sure to include the finding of a(n) _______bladder.

Overdistended An overdistended bladder, which displaces the uterus above and to the right of the umbilicus, can cause uterine atony and lead to hemorrhage.

Documentation related to vacuum delivery includes which of the following:(select all that apply) a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head d. Maternal position

a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head

Eye movements are an example of newborn/infant style of communication. T/F

True Crying, cooing, facial expressions, eye movements, cuddling, and arm and leg movements are all examples of newborn/infant style of communication.

Abruptio placenta is a risk factor for amniotic fluid embolism. T/F

True Risk factors for amniotic fluid embolism include induction of labor, maternal age >35, operative delivery, placenta previa, abruptio placenta, polyhydramnios, eclampsia, and cervical or uterine lacerations.

The perinatal nurse teaches the postpartum woman that the most critical time to achieve effectiveness from the application of ice packs to the perineum is during the first 24 hours following birth. T/F

True To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth.

Which of the following are primary risk factors for subinvolution of the uterus? (SATA) a. Fibroids b. Retained placental tissue c. Metritis d. Urinary tract infection

a. Fibroids b. Retained placental tissue c. Metritis

The perinatal nurse includes the following when explaining the physiology of artificial rupture of membranes to the student nurse: ―rupture of membranes causes a release of arachidonic acid, which converts to prostaglandins, substances known to stimulate oxytocin in the pregnant uterus. T/F

True At certain points in the labor, an amniotomy, or artificial rupture of the membranes, may be successful in increasing uterine contractility

The nurse assessing a newborn for heat loss is aware that non-shivering thermogenesis utilizes the newborn's stores of brown adipose tissue (BAT) to provide heat in the cold-stressed newborn. T/F

True Brown adipose tissue, also known as ―brown fat,‖ is a unique highly vascular fat found only in newborns. BAT derives its name from the rich abundance of blood vessels, cells, and nerve endings that cause it to appear dark in color. The masses of brown fat cells accelerate triglyceride metabolism, triggering a process that produces heat.

The perinatal nurse describes asynclitism to students as a presentation that occurs when the fetal head is turned toward the maternal sacrum or symphysis at an oblique angle. T/F

True Face and brow presentations are examples of asynclitism (the fetal head is presenting at a different angle than expected). Face and brow presentations hyperextend the neck and increase the overall circumference of the presenting part. These presentations are uncommon and are usually associated with fetal anomalies

Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb 13 oz daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominus diastasis

a. Afterpains

Four women are close to delivery on the labor and delivery unit. The nurse knows to be vigilant to the signs of neonatal respiratory distress in which delivery? a. 42-week-gestation pregnancy complicated by intrauterine growth restriction b. 41-week-gestation pregnancy with biophysical profile score of 10 that morning c. 40-week-gestation pregnancy with estimated fetal weight of 3200 grams d. 39-week-gestation pregnancy complicated by maternal cholecystitis

a. 42-week-gestation pregnancy complicated by intrauterine growth restriction

The provision of support during labor has demonstrated that women experience a decrease in anxiety and a feeling of being in more control. In clinical situations, this has resulted in: a. A decrease in interventions b. Increased epidural rates c. Earlier admission to the hospital d. Improved gestational age

a. A decrease in interventions

A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the following symptoms would the nurse expect to see? a. Abdominal distension b. Polyuria c. Diastasis recti d. Dependent edema

a. Abdominal distension

Contraindications for induction of labor include: (select all that apply) a. Abnormal fetal position b. Postdated pregnancy c. Pregnancy-induced hypertension d. Placental abnormalities

a. Abnormal fetal position d. Placental abnormalities

The nurse is teaching the parents of a female baby how to change a baby's diapers. Which of the following should be included in the teaching? a. Always wipe the perineum from front to back. b. Remove any vernix caseosa from the labia folds. c. Put powder on the buttocks every time the baby stools. d. Weigh every diaper in order to assess for hydration.

a. Always wipe the perineum from front to back.

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. The nurse advises the woman that if she experiences unilateral breast inflammation, she should do which of the following? a. Apply warm soaks to the reddened area b. Consume an herbal galactagogue c. Bottle feed the baby during the next day d. Take expressed breastmilk to the laboratory for analysis

a. Apply warm soaks to the reddened area

Which of the following nursing actions can assist a man in his transition to fatherhood? (SATA) a. Ask the man to share his ideas of what it means to be a father b. Demonstrate infant care such as diapering and feeding c. Engage couple in a discussion regarding each others expectations of the fathering role d. Provide the man with information on infant care

a. Ask the man to share his ideas of what it means to be a father b. Demonstrate infant care such as diapering and feeding c. Engage couple in a discussion regarding each others expectations of the fathering role d. Provide the man with information on infant care

It would be most important for a nurse caring for a mother and the infant in the fourth stage of labor to do which of the following? (SATA) a. Assess and massage the fundus every 15 minutes or more often if needed b. Massage the uterus continuously c. Administer oxytocin per protocol d. Assess the patient for a distended bladder

a. Assess and massage the fundus every 15 minutes or more often if needed c. Administer oxytocin per protocol d. Assess the patient for a distended bladder

Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 weeks gestation. An appropriate nursing action would be to (select all that apply): a. Assess the fetal heart rate b. Obtain urine for culture and sensitivity c. Assess Kerrys blood pressure and pulse d. Palpate Kerrys abdomen for contractions

a. Assess the fetal heart rate b. Obtain urine for culture and sensitivity d. Palpate Kerrys abdomen for contractions

A nurse is completing the initial assessment on a neonate of a mother with type I diabetes. Important assessment areas for this neonate include which of the following? (Select all that apply.) a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system

a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system

The nursery nurse notes the presence of diffuse edema on a baby girl's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edemahas disappeared. The nurse documents the following condition in the infant's chart. a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls

a. Caput succedaneum

The perinatal nurse providing care to a laboring woman recognizes a category II, fetal heart rate tracing. The most appropriate initial action is to: a. Assist the laboring woman to a left lateral position b. Decrease the intravenous solution c. Request that the physician/certified nurse-midwife come to the hospital STAT d. Document the fetal heart rate and variability

a. Assist the laboring woman to a left lateral position

The nurse uses the external electronic fetal heart monitor to evaluate fetal status. The fetal heart tracing shows accelerations. Accelerations in the fetal heart are: a. Associated with fetal well-being and oxygenation b. An indication of potential fetal intolerance to labor c. Never associated with the uterine contraction pattern d. A reason to notify the care provider

a. Associated with fetal well-being and oxygenation

General skin care for full-term infants includes which of the following?(Select all that apply.) a. Avoid daily bathing with soap. b. Use a cleanser with an alkaline pH. c. Avoid fragrant soaps. d. Apply petrolatum-based ointments sparingly to dry skin but avoid head and face.

a. Avoid daily bathing with soap. c. Avoid fragrant soaps. d. Apply petrolatum-based ointments sparingly to dry skin but avoid head and face.

The nurse knows that a FHR monitor printout indicates a Category III abnormal fetal heart rate pattern when: a. Baseline variability is minimal or absent with decelerations. b. FHR mirrors the uterine contractions. c. Occasional periodic accelerations occur. d. Baseline variability is 6 to 25 bpm with decelerations

a. Baseline variability is minimal or absent with decelerations.

A woman you are caring for in labor requests an epidural for pain relief in labor. Included in your preparation for epidural placement is a baseline set of vital signs. The most common vital sign to change after epidural placement: a. Blood pressure, hypotension b. Blood pressure, hypertension c. Pulse, tachycardia d. Pulse, bradycardia

a. Blood pressure, hypotension

Which of the following is an indication for the the administration of methylergonovine? a. Boggy uterus that does not respond to massage and oxytocin therapy b. Woman with a large hematoma c. Woman with a deep vein thrombosis d. Woman with severe postpartum depression

a. Boggy uterus that does not respond to massage and oxytocin therapy

A woman is considered in active labor when: a. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to 80%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. b. Cervical dilation progresses to 3 cm with effacement of 30, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds. c. Cervical dilation progresses to 8 cm with effacement of 80%, contractions become more intense, occurring every 2to 5 minutes with duration of 45 to 60 seconds. d. Cervical dilation progresses to 10 cm with effacement of90%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.

a. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to 80%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.

A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing for signs of feeding tolerance? (Select all that apply.) a. Check for presence of bowel sounds b. Assess temperature c. Check gastric residual by aspirating stomach contents d. Assess stools

a. Check for presence of bowel sounds c. Check gastric residual by aspirating stomach contents d. Assess stools

The perinatal nurse describes for the new nurse the various risks associated with prolonged premature preterm rupture of membranes. These risks include (select all that apply): a. Chorioamnionitis b. Abruptio placentae c. Operative birth d. Cord prolapse

a. Chorioamnionitis b. Abruptio placentae d. Cord prolapse

The perinatal nurse describes risk factors for placenta previa to the student nurse. Placenta previa risk factors include (select all that apply): a. Cocaine use b. Tobacco use c. Previous cesarean birth d. Previous use of medroxyprogesterone (Depo-Provera)

a. Cocaine use b. Tobacco use c. Previous cesarean birth

Hyperstimulation is defined as: (select all that apply) a. Contractions lasting more than 2 minutes b. Five or more contractions in 10 minutes c. Contractions occurring within 1 minute of each other d. Uterine resting tone below 20 mm/Hg

a. Contractions lasting more than 2 minutes b. Five or more contractions in 10 minutes c. Contractions occurring within 1 minute of each other

Which of the following actions can decrease the risk for a postpartum infection? (SATA) a. Diet high in protein and vitamin C b. Increased fluid intake c. Ambulating within a few hours after delivery d. Washing nipples with soap prior to each breastfeeding session

a. Diet high in protein and vitamin C b. Increased fluid intake c. Ambulating within a few hours after delivery

Which of the following are common assessment findings of postmature neonates? (Select all that apply.) a. Dry and peeling skin b. Abundant vernix caseosa c. Hypoglycemia d. Thin, wasted appearance

a. Dry and peeling skin c. Hypoglycemia d. Thin, wasted appearance

Which of the following factors increases the risk of necrotizing enterocolitis (NEC) in very premature neonates? (Select all that apply.) a. Early oral feedings with formula b. Prolonged use of mechanical ventilation c. Hyperbilirubinemia d. Nasogastric feedings

a. Early oral feedings with formula d. Nasogastric feedings

The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour. Information provided about preterm labor and birth prevention includes (select all that apply): a. Encouraging regular, ongoing prenatal care b. Reporting symptoms of urinary frequency and burning to the health-care provider c. Coming to the labor triage unit if back pain or cramping persist or become regular d. Lying on the right side, withholding fluids, and counting fetal movements if contractions occur every 5minutes

a. Encouraging regular, ongoing prenatal care b. Reporting symptoms of urinary frequency and burning to the health-care provider c. Coming to the labor triage unit if back pain or cramping persist or become regular

A nurse is caring for a 2-day-old neonate who was born at 31 weeks' gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS). Which of the following medical treatments would the nurse anticipate for this neonate? (Select all that apply.) a. Exogenous surfactant b. Corticosteroids c. Continuous positive airway pressure (CPAP) d. Bronchodilators

a. Exogenous surfactant c. Continuous positive airway pressure (CPAP)

The nurse is caring for a postpartum woman who gave birth to a healthy, full term baby girl. She has a 2-year-old son. She voices concern about her older sons adjustment to the new baby. Nursing actions that will facilitate the older sons adjustment to having a new baby in the house would include which of the following? (SATA) a. Explain to the mother that she can have her son lie in bed with her when he is visiting her in the hospital b. Teach her son how to change the babys diapers c. Assist her son in holding his new baby sister d. Recommend that she spend time reading to her older son while he sits in her lap

a. Explain to the mother that she can have her son lie in bed with her when he is visiting her in the hospital c. Assist her son in holding his new baby sister d. Recommend that she spend time reading to her older son while he sits in her lap

A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer their questions. b. Remove the neonate from the room so the parents will not be distressed by seeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.

a. Explain to the parents the action of the medication and answer their questions.

Documentation related to vacuum delivery includes which of the following: a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head d. Maternal position

a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head

The perinatal nurse recognizes that a risk factor for postpartum depression is: a. Inadequate social support b. Age >35 years c. Gestational hypertension d. Regular schedule of prenatal care

a. Inadequate social support

A neonatal nurse caring for newborns knows that the best time for a mother to first attempt breastfeeding is during which one of the following stages of activity? a. First period of reactivity b. First period of inactivity and sleep c. Second period of reactivity d. Second period of inactivity and sleep

a. First period of reactivity

A nurse is caring for a woman who is 4 hours post-cesarean birth for arrest of labor. The labor and operative records indicate that she had premature rupture of membranes followed by 36 hours of labor. Her IV fluid intake for the past 24 hours is 2500 mL. The estimated blood loss is 1500 mL. Based on this data, the woman is at risk for which of the following? (Select all that apply.) a. Fluid volume deficit b. Infection c. Impaired mother infant attachment d. Falls

a. Fluid volume deficit b. Infection c. Impaired mother infant attachment

A baby boy was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby? a. Grunting b. Acrocyanosis c. Pseudostrabismus d. Hydrocele

a. Grunting

A woman who gave birth 2 hours ago has a temperature of 37.9C. Select all of the immediate nursing actions: a. Have patient drink 2 glasses of fluid over the next hour b. Explain to the patient that she needs to rest and assist her into a comfortable position c. Medicate the patient with 500mg of acetaminophen as per orders d. call the patients physician or midwife to report the elevated temperature

a. Have patient drink 2 glasses of fluid over the next hour b. Explain to the patient that she needs to rest and assist her into a comfortable position

A primiparous woman has been admitted at 35 weeks gestation and diagnosed with HELLP syndrome. Which of the following laboratory changes is consistent with this diagnosis? a. Hematocrit dropped to 28%. b. Platelets increased to 300,000 cells/mm3. c. Red blood cells increased to 5.1 million cells/mm3. d. Sodium dropped to 132 mEq/dL.

a. Hematocrit dropped to 28%.

Approximately 8 hours ago, Juanita, a 32 yo G1 P0, gave birth after 2 hours of pushing. She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9lb 9oz). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels full and is approximately 4cm in diameter. Juanita describes this area as very tender. The most likely cause of these signs and symptoms is: a. Hematoma formation b. Sepsis in the episiotomy site c. Inadequate repair of the episiotomy d. Postpartum hemorrhage

a. Hematoma formation

Which of the following signs or symptoms would the nurse expect to see in a woman with concealed abruptio placentae? a. Increasing abdominal girth measurements b. Profuse vaginal bleeding c. Bradycardia with an aortic thrill d. Hypothermia with chills

a. Increasing abdominal girth measurements

A mother of a 10-day-old infant calls the clinic and reports that her baby is having loose, green stools. The mother is breastfeeding her infant. Which of the following is the best nursing action? a. Instruct the woman to bring her infant to the clinic. b. Instruct the woman to decrease the amount of feeding for 24 hours and to call if the stools continue to be loose. c. Explain that this is a normal stool pattern. d. Instruct the woman to eat a bland diet for the next 24 hours and call back if the stools continue to be loose and green.

a. Instruct the woman to bring her infant to the clinic.

The nurse is working with a 36 yo, married client, G6 P6, who smokes. The woman states, I don't expect to have any more kids, but I hate the thought of being sterile. Which of the following contraceptive methods would be best for the nurse to recommend to this client? a. Intrauterine device b. Contraceptive patch c. Bilateral tubal ligation d. Birth control pills

a. Intrauterine device

Augmentation of labor: a. Is part of the active management of labor instituted when the labor process is unsatisfactory and uterine contractions are inadequate b. Relies on more invasive methods when oxytocin and amniotomy have failed c. Is elective induction of labor d. Is an operative vaginal delivery that uses vacuum cups

a. Is part of the active management of labor instituted when the labor process is unsatisfactory and uterine contractions are inadequate

To accurately measure the neonate's head, the nurse places the measuring tape around the head: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lip

a. Just above the ears and eyebrows

A neonate is born at 33 weeks' gestation with a birth weight of 2400 grams. This neonate would be classified as: a. Low birth weight b. Very low birth weight c. Extremely low birth weight d. Very premature

a. Low birth weight

Mrs. H is telling you she feels the urge to push. This is most likely caused by what? a. Low fetal station triggering the Ferguson reflex b. A fetal position of occiput posterior (OP) c. The second stage of labor d. Transition phase

a. Low fetal station triggering the Ferguson reflex

19. The clinic nurse teaches expectant mothers about the differences between breast milk and commercially prepared infant formulas. When compared to commercially prepared formulas, breast milk has (select all that apply): a. More carbohydrates b. Less protein c. Fewer nutrients d. Less cholesterol

a. More carbohydrates b. Less protein

During the postpartum assessment, the perinatal nurse notes that a patient who has just experienced a forceps-assisted birth now has a large quantity of bright red bleeding. Her uterine fundus is firm. The nurse's most appropriate action is to notify the physician/certified nurse midwife and describe a: a. Need for vaginal assessment and repair b. Requirement for an oxytocin infusion c. Need for further information for the woman/family about forceps d. Requirement for bladder assessment and catheterization

a. Need for vaginal assessment and repair

A nurse is caring for a 40 weeks' gestation neonate. The neonate is 12 hours postbirth and has been admitted to the NICU for meconium aspiration. The nurse recalls that the following are potential complications related to meconium aspiration (select all that apply): a. Obstructed airway b. Hyperinflation of the alveoli c. Hypoinflation of the alveoli d. Decreased surfactant proteins

a. Obstructed airway b. Hyperinflation of the alveoli d. Decreased surfactant proteins

The best time to give prophylactic antibiotics to the women undergoing cesarean section is: a. One hour before the surgery b. Two hours before the surgery c. Not indicated unless she has an active infection d. At the time the cord is clamped

a. One hour before the surgery

The perinatal nurse observed the pediatrician completing the Ballard Gestational Age by Maturity Rating tool. The maturity components used with this assessment tool are (select all that apply): a. Physical b. Behavioral c. Reflexive d. Neuromuscular

a. Physical d. Neuromuscular

Tanya, a 30-year-old woman, is being prepared for an elective cesarean birth. The perinatal nurse assists the anesthesiologist with the spinal block and then positions Tanya in a supine position. Tanyas blood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm. The perinatal nurses best response is to: a. Place a wedge under Tanyas left hip. b. Discontinue Tanyas intravenous administration. c. Have naloxone (Narcan) ready for administration. d. Have epinephrine ready for administration

a. Place a wedge under Tanyas left hip.

The perinatal nurse teaches the student nurse that deep breathing exercises following a cesarean birth are critical to the prevention of (select all that apply): a. Pneumonia b. Atelectasis c. Abdominal distension d. Increased tidal

a. Pneumonia b. Atelectasis

A first-time mother informs her nurse that another staff member came in and wanted to take her baby to the nursery. The mother refused to let the woman take her baby because the staff member did not have a picture ID. The nurse should do which of the following? (Select all that apply.) a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.

a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.

The perinatal nurse is assisting the student nurse with completion of documentation. The laboring woman has just given birth to a 2700-gram infant at 36 weeks' gestation. The most appropriate term for this is: a. Preterm birth b. Term birth c. Small for gestational age infant d. Large for gestational age infant

a. Preterm birth

The physician has ordered intravenous oxytocin for induction for four gravidas. In which of the following situations should the nurse refuse to comply with the order? a. Primigravida with complete placenta previa b. Multigravida with extrinsic asthma c. Primigravida who is 38 years old d. Multigravida who is colonized with group B streptococci

a. Primigravida with complete placenta previa

The perinatal nurse notes a rapid decrease in the fetal heart rate that does not recover immediately following an amniotomy. The most likely cause of this obstetrical emergency is: a. Prolapsed umbilical cord b. Vasa previa c. Oligohydramnios d. Placental abruption

a. Prolapsed umbilical cord

The laboratory reported that the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid client with preeclampsia are 2:1. The nurse interprets the result as which of the following? a. The baby's lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby's kidneys are functioning poorly. d. The mother is high risk for eclampsia.

a. The baby's lung fields are mature.

An infant admitted to the newborn nursery has a blood glucose level of 55mg/dL. Which of the following actions should the nurse perform at this time? a. Provide the baby with routine feedings. b. Assess the baby's blood pressure. c. Place the baby under the infant warmer. d. Monitor the baby's urinary output.

a. Provide the baby with routine feedings.

The nurse is developing a plan of care for a client who is in the taking-in phase after delivering a healthy baby boy. Which of the following should the nurse include in the plan? a. Provide the client with a nutritious meal b. Teach baby care skills like diapering c. Discuss the pros and cons of circumcision d. Counsel her regarding future sexual encounters

a. Provide the client with a nutritious meal

Which of the following nursing actions are directed at promoting bonding? (SATA) a. Providing opportunity for parents to hold their newborn as soon as possible following the birth b. Providing opportunities for the couple to talk about their birth experience and about becoming parents c. Promoting rest and comfort by keeping the newborn in the nursery at night d. Providing positive comments to parents regarding their interactions with their newborn

a. Providing opportunity for parents to hold their newborn as soon as possible following the birth b. Providing opportunities for the couple to talk about their birth experience and about becoming parents d. Providing positive comments to parents regarding their interactions with their newborn

The nurse is advising parents of a full-term neonate being discharged fromthe hospital regarding car seat safety. Which of the following should be included in the teaching plan? a. Put the car seat facing forward only after the baby reaches 20 pounds. b. The infant car seat should be placed facing the rear seat in the front seat of the car. c. A fist should fit between the straps of the seat and the baby's body. d. Seat belt adjusters should always be used to support infant car seats.

a. Put the car seat facing forward only after the baby reaches 20 pounds.

The nurse is assisting a physician in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? a. Risk for injury b. Colonic constipation c. Risk for impaired parenting d. Ineffective individual coping

a. Risk for injury

Which of the following breath sounds are normal to hear in the neonate during the first few hours postbirth? a. Scattered crackles b. Wheezes c. Stridor d. Grunting

a. Scattered crackles

Which of the following factors place a new mother at risk for parenting? (SATA) a. She is 17 years old b. Family income is below the average income c. Her parents live in the same city and are perceived as helpful d. She dropped out of school at age 13

a. She is 17 years old b. Family income is below the average income d. She dropped out of school at age 13

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform? a. Supervise all infant care b. Maintain client on strict bedrest c. Rerstrict visitation to just her partner d. Carefully monitor toileting

a. Supervise all infant care

Which statement correctly describes the nurse's responsibility related to electronic fetal monitoring? a. Teach the woman and her family about the monitoring equipment and discuss any questions they have. b. Report abnormal findings to the care provider before initiating corrective actions. c. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place. d. Document the frequency, duration, and intensity of contractions measured by the external device.

a. Teach the woman and her family about the monitoring equipment and discuss any questions they have.

A nurse is assisting a physician during a baby's circumcision. Which of the following demonstrates that the nurse is acting as the baby's patient care advocate? a. The nurse requests that oral sucrose be ordered as a pain relief measure. b. The nurse restrains the baby on the circumcision board. c. The nurse wears a surgical mask during the procedure. d. The nurse provides the physician with an iodine solution for cleansing the skin.

a. The nurse requests that oral sucrose be ordered as a pain relief measure.

The postpartum nurse caring for a 20 yo G1 P0 woman who 3 hours ago delivered a healthy full-term infant, observes the woman who is lightly touching her baby girl with her fingertips but who seems to be uncomfortable holding her baby close to her body. Which of the following is an accurate interpretation of these observed behaviors? a. The woman is in the initial stage of maternal touch b. The woman is in the taking-in phase c. The woman is having difficulty in bonding with her baby d. The woman needs to be medicated for pain

a. The woman is in the initial stage of maternal touch

A pregnant woman who has a history of cesarean births is requesting to have a vaginal birth after cesarean (VBAC). In which of the following situations should the nurse advise the patient that her request may be declined? a. Transverse fetal lie b. Flexed fetal attitude c. Previous low flap uterine incision d. Positive vaginal candidiasis

a. Transverse fetal lie

After assessing the FHR tracing shown below, which of the following interventions should the nurse perform? a. Turn the woman on her side. b. Administer oxygen by nasal cannula. c. Encourage the patient to push with each contraction. d. Provide the patient with caring labor support

a. Turn the woman on her side.

For the patient with which of the following medical problems should the nurse question a physicians order for beta agonist tocolytics? a. Type 1 diabetes mellitus b. Cerebral palsy c. Myelomeningocele d. Positive group B streptococci culture

a. Type 1 diabetes mellitus

Nursing actions that decrease the risk of skin breakdown include which of the following? (Select all that apply.) a. Using gelled mattresses b. Using emollients in groin and thigh areas c. Using transparent dressings d. Drying thoroughly

a. Using gelled mattresses b. Using emollients in groin and thigh areas c. Using transparent dressings

The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include (select all that apply): a. Vocalizations b. Mouth movements c. Moving the hand to the mouth d. Yawning

a. Vocalizations b. Mouth movements c. Moving the hand to the mouth

Nursing actions focused at reducing a postpartum womans risk for cystitis include which of the following? (SATA) a. Voiding within a few hours post-birth b. Oral intake of a minimum of 1000mL per day c. Changing peri-pads every 3 to 4 hours or more frequently as indicated d. Reminding the woman to void every 3 to 4 hours while awake

a. Voiding within a few hours post-birth c. Changing peri-pads every 3 to 4 hours or more frequently as indicated d. Reminding the woman to void every 3 to 4 hours while awake

The nurse is about to elicit the rooting reflex on a newborn baby. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends

a. When the cheek of the baby is touched, the newborn turns toward the side that is touched.

The nurse explains to a pregnant patient that the mother's prior exposure to illness and immunizations prompts the development of antibodies in the newborn in a process termed ________ immunity.

active acquired

The perinatal nurse assists the nursing student who is preparing the patient with oligohydramnios for a fluid infusion into the uterine cavity. This procedure is described as a(n)

amnioinfusion

The nurse is assessing the neonate's skin and notes the presence of small, irregular, red patches on the cheeks that will develop into single, yellow pimples on the chest or abdomen. The name for this common neonatal skin condition is: a. Milia b. Neonatal acne c. Erythema toxicum d. Pustular melanosis

c. Erythema toxicum

A woman is 2 days postpartum from a normal vaginal delivery of a 3000-gram baby. Where would the nurse expect to palpate the client's fundus? a. At the umbilicus b. 2 cm below umbilicus c. 2 cm above symphysis d. at the symphysis

b. 2 cm below umbilicus

A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? (Select all that apply.) a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. The neonate's lung sounds may sound moist during early auscultation

b. A breathing pattern that is often shallow, diaphragmatic, and irregular d. The neonate's lung sounds may sound moist during early auscultation

The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will be receiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse: a. Assists the woman to lie down in a supine position. b. Administers a rapid intravenous infusion of 500 mL of normal saline. c. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion. d. Encourages frequent cleansing breaths after the patient has been placed in the correct position for the anesthesia administration.

b. Administers a rapid intravenous infusion of 500 mL of normal saline.

The perinatal nurse caring for Emily, a 24-year-old mother of an infant born at 26 weeks' gestation, is providing discharge teaching. Emily is going to travel to the specialty center approximately 200 miles away where her daughter is receiving care. The nurse tells Emily that it is normal for Emily to feel (select all that apply): a. In control b. Anxious c. Guilty d. Overwhelmed

b. Anxious c. Guilty d. Overwhelmed

A 25 yo woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms b. Assess the location and firmness of the fundus c. Change her pad and return in 1 hour to reassess d. Give her 10 units of oxytocin as per standing order

b. Assess the location and firmness of the fundus

A nurse is preparing to monitor a patient who is to receive an amnioinfusion. Which of the following actions should the nurse make at this time? a. Attach the patient to an electronic blood pressure cuff. b. Assist in insertion of an internal uterine pressure catheter. c. Attach the patient to an oxygen saturation monitor. d. Perform an amniotic fluid Nitrazine test.

b. Assist in insertion of an internal uterine pressure catheter.

A woman at 10 weeks gestation is diagnosed with gestational trophoblastic disease (hydatidiform mole). Which of the following findings would the nurse expect to see? a. Platelet count of 550,000/mm3 b. Dark brown vaginal bleeding c. White blood cell count 17,000/mm3 d. Macular papular rash

b. Dark brown vaginal bleeding

You are caring for a primiparous woman admitted to labor and delivery for induction of labor at 42 weeks' gestation. She asks you to explain the factors that contribute to prolonged labor. The best response would be to state the following: a. Primiparous women are not at risk for dystocia because they usually have small babies. b. Dystocia is related to uterine contractions, the pelvis, the fetus, the position of the mother, and psychosocial response. c. Labor is primarily associated with pelvic abnormalities. d. Dystocia is typically diagnosed prior to labor based on pelvimetry

b. Dystocia is related to uterine contractions, the pelvis, the fetus, the position of the mother, and psychosocial response.

The mechanism of labor known as cardinal movements of labor are the positional changes that the fetus goes through to best navigate the birth process. These cardinal movements are: a. Engagement, Descent, Flexion, Extension, Internal rotation, External rotation, Expulsion b. Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion c. Engagement, Flexion, Internal rotation, Extension, External rotation, Descent, Expulsion d. Engagement, Flexion, Internal rotation, Extension, External rotation, Flexion, Expulsion

b. Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion

A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions? a. Phototherapy b. Feeding neonate every 2 to 3 hours c. Switch from breastfeeding to bottle feeding d. Assess red blood cell count

b. Feeding neonate every 2 to 3 hours

Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5, who is 1 hour postdelivery? a. Nipples b. Fundus c. Lungs d. Rectum

b. Fundus

The perinatal nurse is teaching the new mother who has chosen to formula feed her infant. Appropriate instructions to be given to this mother include (select all that apply): a. Mix the formula with hot water only. b. Periodically check the nipple for slow flow. c. Prepare only enough formula to last for 24 hours. d. Discard any unused formula that remains in a bottle following use.

b. Periodically check the nipple for slow flow. c. Prepare only enough formula to last for 24 hours. d. Discard any unused formula that remains in a bottle following use.

A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip? a. Grasp the inner aspects of the baby's calves with thumbs and forefingers. b. Gently abduct the baby's thighs. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.

b. Gently abduct the baby's thighs.

Which of the following are disadvantages of bottle feeding? (Select all that apply.) a. Hampers mother-infant attachment b. Increases cost c. Increases risk of infection d. Increases risk of childhood obesity

b. Increases cost c. Increases risk of infection d. Increases risk of childhood obesity

The let-down reflex occurs in response to the release of oxytocin. Which of the following can stimulate the release of oxytocin? (Select all that apply.) a. Prolactin release b. Infant suckling c. Infant crying d. Sexual activity

b. Infant suckling c. Infant crying d. Sexual activity

A labor nurse is caring for a patient, 39 weeks gestation, who has been diagnosed with placenta previa. Which of the following physician orders should the nurse question? a. Type and cross-match her blood. b. Insert an internal fetal monitor electrode. c. Administer an oral stool softener. d. Assess her complete blood count.

b. Insert an internal fetal monitor electrode.

Your patient is a 28-year-old gravida 2 para 1 in active labor. She has been in labor for 12 hours. Upon further assessment, the nurse determines that she is experiencing a hypotonic labor pattern. Possible maternal and fetal implications from hypotonic labor patterns are: a. Intrauterine infection and maternal exhaustion with fetal distress usually occurring early in labor. b. Intrauterine infection and maternal exhaustion with fetal distress usually occurring late in labor. c. Intrauterine infection and postpartum hemorrhage with fetal distress early in labor. d. Intrauterine infection and ruptured uterus and fetal death.

b. Intrauterine infection and maternal exhaustion with fetal distress usually occurring late in labor.

During a cesarean section, which action by the nurse is done to prevent compression of the descending aorta and vena cava? a. Right lateral tilt b. Left lateral tilt c. Elevate head of gurney at 30 degrees d. Administration of IV fluid preload of 500 to 1000 mL

b. Left lateral tilt

During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is: a. To notify the patients midwife or physician b. Massage the fundus until firm and then reevaluate within 30 mins c. Give Syntocinon as per orders d. Assist patient to bathroom and ask her to void

b. Massage the fundus until firm and then reevaluate within 30 mins

Karen, a G2 P1, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. The nurses most appropriate first action is to: a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Ensure appropriate lighting for a perineal repair if it is needed.

b. Massage the uterine fundus with continual lower segment support.

The nurse assesses that a full-term neonate's temperature is 36.2°C. The first nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.

b. Place the neonate on the mother's chest with a warm blanket over the mother and baby.

Which of the following neonatal signs or symptoms would the nurse expect to see in a neonate with an elevated bilirubin level? a. Low glucose b. Poor feeding c. Hyperactivity d. Hyperthermia

b. Poor feeding

Typical signs of abusive head trauma (Shaken Baby Syndrome) include which of the following? (Select all that apply.) a. Broken clavicle b. Poor feeding c. Vomiting d. Breathing problems

b. Poor feeding c. Vomiting d. Breathing problems

The perinatal nurse understands that the purpose of combining an opioid with a local anesthetic agent in an epidural is primarily to: a. Increase the total anesthetic volume b. Preserve a greater amount of maternal motor function c. Increase the intensity of the motor and sensory block d. Decrease the number of side effects

b. Preserve a greater amount of maternal motor function

Ms. M is 38 weeks gestation and is a G1 P0. At 10 pm Ms. M has just been informed by the nurse that she is 3 to 4 cm dilated, cervix is 100% effaced, and contractions are every 4 to 5 minutes. When the nurse tells her the findings from the SVE, Ms. M states that she had been contracting since early that morning and she becomes extremely frustrated stating I should have had this baby by now. What is the best response by the nurse? a. Remind her that length of labor for the first child can be 18 to 24 hours b. Promote relaxation techniques c. Discuss various analgesic options d. Tell Ms. M that the provider will be contacted immediately about the slow progress of labor

b. Promote relaxation techniques

A primigravida woman at 42 weeks' gestation received Prepidil (dinoprostone) for induction 12 hours ago. The Bishop score is now 3. Which of the following actions by the nurse is appropriate? a. Perform Nitrazine analysis of the amniotic fluid. b. Report the lack of progress to the obstetrician. c. Place the woman on her left side. d. Ask the doctor for an order for oxytocin

b. Report the lack of progress to the obstetrician.

The perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This stage of mothering is best described as: a. Taking in b. Taking hold c. Taking charge d. Taking time

b. Taking hold

The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation. Support for the lower uterine segment is critical, as without it, there is an increased risk of: a. Uterine edema b. Uterine inversion c. Incorrect measurement d. Intensifying the patient's level of pain

b. Uterine inversion

The nurse is caring for a recently immigrated Chinese woman in the postpartum unit. Based on cultural beliefs and practices of the woman, the nurse would anticipate which of the following? (SATA) a. The woman prefers cold water for drinking b. The woman prefers not to shower c. The woman prefers to have her female relatives care for her baby d. The woman prefers to have her family bring her food to eat

b. The woman prefers not to shower c. The woman prefers to have her female relatives care for her baby d. The woman prefers to have her family bring her food to eat

A nurse is going to teach her postpartum patient about newborn bathing, diapering, and swaddling. Which of the following indicates that the nurse incorporated teaching/learning principles in her teaching plans? (Select all that apply.) a. Asked family members to leave b. Turned off TV c. Closed the door of the room d. Administered analgesics a few hours before teaching session

b. Turned off TV c. Closed the door of the room d. Administered analgesics a few hours before teaching session

The perinatal nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the HCP include the development of a fever and: a. Breast engorgement b. Uterine tenderness c. Diarrhea d. Emotional lability

b. Uterine tenderness

The perinatal nurse is teaching her new mother about breastfeeding and explains that the most appropriate time to breastfeed is: a. 3 to 4 hours after the last feeding b. When her infant is in a quiet alert state c. When her infant is in an active alert state d. When her infant exhibits hunger-related crying

b. When her infant is in a quiet alert state

A low-risk patient calls the labor unit and says I need to come in to be checked right now, there were pink streaks on the toilet paper when I went to the bathroom. I think I'm bleeding. What response should the nurse say first? a. How much blood is there? b. You sound concerned, what other labor symptoms do you have? c. Don't worry that sounds like a mucus plug. d. Does it burn when you urinate?

b. You sound concerned, what other labor symptoms do you have?

The nurse notes that a new father gazes at his baby for prolonged periods of time and comments that his baby is beautiful and he is very happy having a baby. These behaviors are commonly associated with: a. Bonding b. engrossment c. couvade syndrome d. attachment

b. engrossment

In caring for a primiparous woman in labor, one of the factors to evaluate is uterine activity. This is referred to as the ______ of labor a. passenger b. passage c. powers d. psyche

b. powers

The perinatal nurse explains to the student nurse who is assessing the abdomen of a 32-week pregnant woman with placenta previa that it would not be unusual to find the fetus in a _______ or _______ position

breech, transverse Placenta previa is an implantation of the placenta in the lower uterine segment, near or over the internal cervical os. This condition accounts for 20% of all antepartal hemorrhages. Leopold maneuvers often reveal the fetus to be in a breech or oblique position or transverse lie because of the abnormal location ofthe placenta.

The perinatal nurse accurately defines postpartum hemorrhage by including a decrease in hematocrit levels from pre- to postbirth by: a. 5% b. 8% c. 10% d. 15%

c. 10%

A woman who is 36 weeks pregnant presents to the labor and delivery unit with a history of congestive heart disease. Which of the following findings should the nurse report to the primary health-care practitioner? a. Presence of chloasma b. Presence of severe heartburn c. 10-pound weight gain in a month d. Patellar reflexes +1

c. 10-pound weight gain in a month

A 35 yo G1 P0 postpartum woman is Rh0(D)-negative and needs Rh0(D) immune globulin to be administered. The most appropriate dose that the perinatal nurse would expect to be ordered would be: a. 120 ug b. 250 ug c. 300 ug d. 350 ug

c. 300 ug

A postpartum nurse has received an exchange report on the 4 following mother-baby couplets. Based on the information provided, which couplet should the nurse first assess? a. A 25yo G2P1 woman who is 36 hours postbirth and is having difficulty breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is moderate to scant. b. A 16yo G1P0 who will be discharged in the afternoon. It was reported that she refers to her baby boy as it and that she requested to have her baby stay in the nursery so she could sleep. c. A 32yo G5P4 woman who delivered a 4500-gram baby boy 2 hours ago after a 20-hour labor that was augmented. It was reported that her uterus is 2cm above the umbilicus with moderate lochia. d. A 28yo G2P1 woman who delivered a 3800-gram baby girl by elective cesarean birth. She had spinal anesthesia and was given intrathecal preservative-free morphine for postoperative pain management. Her vital signs are BP 115/75, P 80, RR 18, T 98

c. A 32yo G5P4 woman who delivered a 4500-gram baby boy 2 hours ago after a 20-hour labor that was augmented. It was reported that her uterus is 2cm above the umbilicus with moderate lochia.

Which of the following neonates is at highest risk for cold stress? a. A 36 gestational week LGA neonate b. A 32 gestational week AGA neonate c. A 33 gestational week SGA neonate d. A 38 gestational week AGA neonate

c. A 33 gestational week SGA neonate

The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate, 136beats per minute; respiratory rate, 64 breaths per minute; temperature, 98.2°F(36.8°C); length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider? a. Respiratory rate b. Presence of a heart murmur c. Absent bowel sounds d. Weight

c. Absent bowel sounds

A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Encourage the parents to hold the baby. d. Advise the parents to refrain from discussing the baby's death with their other children.

c. Encourage the parents to hold the baby.

The clinical nurse recalls that the newborn has four mechanisms by which heat is lost following birth: evaporation, conduction, convection, and radiation. Which of the following are examples of heat lost via convection? (Select all that apply.) a. An infant loses heat when not dried adequately after birth b. An infant is placed on a cold scale c. An infant is placed under a ceiling fan d. An infant is placed near an open window

c. An infant is placed under a ceiling fan d. An infant is placed near an open window

The perinatal nurse notifies the physician of the findings related to Juanita's assessment. The first step in care will most likely be to: a. Prepare Juanita for surgery b. Administer intravenous fluids c. Apply ice to the perineum d. Insert a urinary catheter

c. Apply ice to the perineum

It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time? a. Perform a gavage feeding immediately. b. Assess the brachial pulse. c. Assist a physician with intubation. d. Stimulate the baby to cry.

c. Assist a physician with intubation.

A woman is 3 hours post-early-postpartum hemorrhage of 800mL at delivery. Select the nursing actions for care of this client: (SATA) a. Limit fluid intake to prevent nausea and vomiting b. Assess fundus every 4 hours during the first 8 hours c. Explain the importance of preventing an overdistended bladder d. Provide assistance with ambulation

c. Explain the importance of preventing an overdistended bladder d. Provide assistance with ambulation

Which of the following clients is most likely to complain of afterbirth pains during her postpartum period? a. G1 P0, diagnosed with preeclampsia b. G2 P0, group B strep positive c. G3 P2, gave birth to a 4100-gram baby d. G4 P1, diagnosed with preterm labor

c. G3 P2, gave birth to a 4100-gram baby

The nurse is teaching the parents of a 1-day-old baby how to give their baby a bath. Which of the following actions should be included? a. Clean the eye from the outer canthus to the inner canthus. b. Keep the door of the room open to allow for ventilation. c. Gather all supplies before beginning the bath. d. Check the temperature of the water with your fingertip.

c. Gather all supplies before beginning the bath

A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complications of pregnancy likely contributed to these findings? a. Pyelonephritis b. Pregnancy-induced hypertension c. Gestational diabetes d. Abruptio placentae

c. Gestational diabetes

The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? a. Intermittent strabismus b. Startling c. Grunting d. Vaginal bleeding

c. Grunting

Which of the following statements indicates that a new mother needs additional teaching? a. I need to supervise my cat when she is in the same room as my baby. b. I will place my baby on her back when she is sleeping. c. I will not leave my baby on an elevated flat surface after she is able to turnover on her own. d. I have asked my husband to install safety latches on the lower cabinets.

c. I will not leave my baby on an elevated flat surface after she is able to turnover on her own.

Which of the following is a medical indication for a cesarean birth? (Select all that apply.) a. Maternal blood pressure of 130/90 b. Cervical dilation of 1.5 cm per hour during the active phase of labor c. Late deceleration of the fetal heart rate with minimal variability d. Complete placenta previa e. Arrest of fetal descent

c. Late deceleration of the fetal heart rate with minimal variability d. Complete placenta previa e. Arrest of fetal descent

During labor induction with oxytocin, the fetal heart rate baseline is in the 140s with moderate variability. Contraction frequency is assessed to be every 2minutes with duration of 60 seconds, of moderate strength to palpation. Based on this assessment, the nurse should take which action? a. Increase oxytocin infusion rate per physician's protocol. b. Stop oxytocin infusion immediately. c. Maintain present oxytocin infusion rate and continue to assess. d. Decrease oxytocin infusion rate by 2 mU/min and report to physician

c. Maintain present oxytocin infusion rate and continue to assess.

Nursing actions that minimize oxygen demands in the neonate include which of the following? (Select all that apply.) a. Providing frequent rest breaks when feeding b. Placing neonate on back for sleeping c. Maintaining a neutral thermal environment (NTE) d. Clustering nursing care

c. Maintaining a neutral thermal environment (NTE) d. Clustering nursing care

A postpartum woman, who gave birth 12 hours ago, is breastfeeding her baby. She tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response for this patient is: a. I understand your concern, but your baby will be okay until your milk comes in. b. Your baby seems content, so you should not worry about him getting enough to eat. c. Milk normally comes in around the third day. Prior to that, he is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health. d. You can bottle feed until your milk comes in.

c. Milk normally comes in around the third day. Prior to that, he is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health.

A baby was born 4 days ago at 34 weeks' gestation. She is receiving phototherapy as ordered by the physician for physiological jaundice. She has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. The nurse's priority nursing action(s) is (are) to (select all that apply): a. Verify laboratory results to check for hypomagnesemia. b. Verify laboratory results to check for hypoglycemia. c. Monitor the baby's temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration

c. Monitor the baby's temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration

You are caring for a woman in labor who is 6 cm dilated with a reassuring FHT pattern and regular strong UCs. The fetal heart rate (FHR) should be: a. Monitored continuously b. Monitored every 15 minutes c. Monitored every 30 minutes d. Monitored every 60 minutes

c. Monitored every 30 minutes

Which of these medications is commonly used to control postpartum bleeding related to uterine atony? a. Magnesium sulfate b. Phytonadione c. Oxytocin d. Warfarin

c. Oxytocin

A woman who is 12 weeks postpartum presents with the following behavior: she reports severe mood swings and hearing voices, believes her infant is going to die, she has to be reminded to shower and put on clean clothes, and she feels she is unable to care for her baby. These behaviors are associated with which of the following? a. Postpartum blues b. Postpartum depression c. Postpartum psychosis d. Maladaptive mother-infant attachment

c. Postpartum psychosis

Which of the following nursing actions are directed at assisting men in their transition to fatherhood? (SATA) a. Encourage the woman to take on the major responsibility for infant care b. Talk to the man, away from his partner, about his expectations of the fathering role c. Praise the father for his interactions with his infant d. Provide information on infant care and behavior to both parents

c. Praise the father for his interactions with his infant d. Provide information on infant care and behavior to both parents

The perinatal nurse knows that tocolytic agents are most often used to (select all that apply): a. Prevent maternal infection b. Prolong pregnancy to 40 weeks gestation c. Prolong pregnancy to facilitate administration of antenatal corticosteroids d. Allow for transport of the woman to a tertiary care facility

c. Prolong pregnancy to facilitate administration of antenatal corticosteroids d. Allow for transport of the woman to a tertiary care facility

A 1-day-old neonate in the well-baby nursery is suspected of suffering from drug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom? a. Prolonged periods of sleep b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash

c. Repeated bouts of diarrhea

A woman at 32 weeks gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positive patient care outcome? a. Rise in serum creatinine b. Drop in serum protein c. Resolution of thrombocytopenia d. Resolution of polycythemia

c. Resolution of thrombocytopenia

A woman who is admitted to labor and delivery at 30 weeks gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for the nurse to assess each hour? a. Temperature b. Pulse c. Respiratory rate d. Blood pressure

c. Respiratory rate

A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician immediately of which of the following findings? a. Patellar and biceps reflexes of +4 b. Urinary output of 50 mL/hr c. Respiratory rate of 10 rpm d. Serum magnesium level of 5 mg/dL

c. Respiratory rate of 10 rpm

The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of: a. Lecithin b. Calcium c. Surfactant d. Magnesium

c. Surfactant

A woman on the day of discharge from the postpartum unit requests clean towels so she can take a shower, asks a number of questions regarding breastfeeding, and shares that she is nervous about taking her baby home and not being able to remember everything she has been taught. These are behaviors associated with: a. Bonding b. Taking in c. Taking hold d. Attachment

c. Taking hold

After an education class, the nurse overhears an adolescent woman discussing safe sex practices. Which of the following comments by the young woman indicates that additional teaching about sexually transmitted infection (STI) control issues is needed? a. I could get an STI even if I just have oral sex. b. Girls over 16 are less likely to get STDs than younger girls. c. The best way to prevent an STI is to use a diaphragm. d. Girls get human immunodeficiency virus (HIV) easier than boys do.

c. The best way to prevent an STI is to use a diaphragm.

When assessing the apical pulse of the neonate, the stethoscope should be placed at the: a. First or second intercostal space b. Second or third intercostal space c. Third or fourth intercostal space d. Fourth or fifth intercostal space

c. Third or fourth intercostal space

A nurse is assessing for the tonic neck reflex. This is elicited by: a. Making a load sound near the neonate. b. Placing the neonate in a sitting position. c. Turning the neonate's head to the side so that the chin is over the shoulder while the neonate is in a supine position. d. Holding the neonate in a semi-sitting position and letting the head slightly drop back.

c. Turning the neonate's head to the side so that the chin is over the shoulder while the neonate is in a supine position.

The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex.

As the perinatal nurse performs an assessment of the infant's head, ears, eyes, nose, and throat, the ears are noted to be low set. This clinical finding would require follow-up due to the potential for _______________.

chromosomal abnormalities

The perinatal nurse knows that a ________ hemorrhage is limited to the uterus, and a _________ hemorrhage moves blood toward and through the cervix.

concealed, revealed A concealed hemorrhage occurs in 20% of cases and describes an abruption in which the bleeding is confined within the uterine cavity. The most common abruption is associated with a revealed or external hemorrhage, where the blood dissects downward toward the cervix. The most common abruption is associated with a revealed or external hemorrhage, where theblood dissects downward toward the cervix.

The perinatal nurse assessing a newborn for jaundice recalls that _____ is a process that converts the yellow lipid-soluble (non-excretable) bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.

conjugation

The perinatal nurse understands that the most appropriate nursing action following an amniotomy is an assessment of the _____ as well as the _____ and ______ of the amniotic fluid.

fetal heart rate; color; odor The nurse carefully monitors the patient who will undergo an amniotomy. Vital signs, cervical effacement and dilation, station of the presenting part, fetalheart rate, and color and amount of amniotic fluid are assessed

On day 4 following the birth of an average size baby, the nurse would expect the fundus to be at: a. 1 cm below umbilicus b. 2 cm below umbilicus c. 3 cm below umbilicus d. 4 cm below umbilicus

d. 4 cm below umbilicus

The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist as soon as possible? a. 1-day-old, HR 170 bpm, crying b. 2-day-old, T 98.9°F, slightly jaundice c. 3-day-old, breastfeeding q 2 h, rooting d. 4-day-old, RR 70 rpm, dusky coloring

d. 4-day-old, RR 70 rpm, dusky coloring

The perinatal nurse contacts the pediatrician about a heart murmur that was auscultated during a routine newborn assessment. This finding would be abnormal at: a. 8 to 12 hours b. 12 to 24 hours c. 24 to 48 hours d. 48 to 72 hours

d. 48 to 72 hours

According to agency policy, the perinatal nurse provides the following intrapartal nursing care for the patient with preeclampsia: a. Take the patients blood pressure every 6 hours b. Encourage the patient to rest on her back c. Notify the physician of urine output greater than 30 mL/hr d. Administer magnesium sulfate according to agency policy

d. Administer magnesium sulfate according to agency policy

If the umbilical cord prolapses during labor, the nurse should immediately: a. Type and cross-match blood for an emergency transfusion. b. Await MD order for preparation for an emergency cesarean section. c. Attempt to reposition the cord above the presenting part. d. Apply manual pressure to the presenting part to relieve pressure on the cord

d. Apply manual pressure to the presenting part to relieve pressure on the cord

Felicity Chan, a new mother, is accompanied by her mother during her hospital stay on the postpartum unit. Felicity's mother makes specific, various requests of the nurses including bringing warm tea, a cot to sleep on, and that the baby not be bathed at this time. Felicity's mother is also concerned about the amount of work that Felicity may be doing in the provision of infant care. Felicity asks for help with breastfeeding. After Felicity has finished breastfeeding, her mother asks for a bottle so they can warm it and feed the baby. How would the perinatal nurse best respond to Felicity's mother in a culturally sensitive way? a. Ask Felicity's mother to leave for 30 minutes to allow for some private time with Felicity to explore her learning needs privately. b. Ask both Felicity and her mother about the preferred infant feeding method and assess what they already know. c. Convey to Felicity and her mother an understanding of the concepts of hot and cold within their belief system. d. Ask Felicity what she knows about breastfeeding and provide information to both women to support Felicity's decision.

d. Ask Felicity what she knows about breastfeeding and provide information to both women to support Felicity's decision.

Heather, a postpartum woman who experienced a spontaneous vaginal birth 12 hours ago, describes a headache that is worsening. Heather was given 2 regular strength acetaminophen (tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. Several friends and family members are presently visiting Heather. The nurse notes that Heather's pain relief during labor consisted of a single dose of an IM narcotic. The most appropriate nursing action at this time is to: a. Notify Heather's health care provider about her headache b. Dim the lights in Heather's room so that she is able to get some rest c. Ask Heather's visitors to leave now to decrease environmental stimuli d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain

d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain

A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural anesthesia. Which of the following interventions should the nurse perform on the mother at this time? a. Maintain the client flat in bed. b. Assess the clients patellar reflexes. c. Monitor hourly urinary outputs. d. Assess the clients respiratory rate.

d. Assess the clients respiratory rate.

The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks gestation in her first pregnancy. She is worried about having her baby too soon, and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be: a. Preterm labor b. Term labor c. Back labor d. Braxton-Hicks

d. Braxton-Hicks

The perinatal nurse knows that the term to describe a woman at 26 weeks gestation with a history of elevated blood pressure who presents with a urine showing 2+ protein (by dipstick) is: a. Preeclampsia b. Chronic hypertension c. Gestational hypertension d. Chronic hypertension with superimposed preeclampsia

d. Chronic hypertension with superimposed preeclampsia

A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which of the following common medication effects would the nurse expect to see in the mother? a. Serum potassium level increases b. Diarrhea c. Urticaria d. Complaints of nervousness

d. Complaints of nervousness

A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection? a. Verify that the direct Coombs test results are positive b. Check that the fetus was at least 28 weeks gestation c. Make sure that the client is at least 3 days postdelivery d. Confirm that the client is Rh negative

d. Confirm that the client is Rh negative

A patient, G1 P0, is admitted to the labor and delivery unit for induction of labor. The following assessments were made on admission: Bishop score of 4, fetal heart rate 140s with good variability and no decelerations, TPR 98.6ºF, 88, 20, BP 120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrant the removal of the Cervidil (dinoprostone)? a. Bishop score of 5 b. Fetal heart of 152 bpm c. Respiratory rate of 24 rpm d. Contraction frequency of every 2 minutes

d. Contraction frequency of every 2 minutes

The perinatal nurse listens as Chantal describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist Chantal in: a. Her role development in the letting go stage b. Decreasing her ambivalence about her labor and birth c. Understanding her guilt involved in her labor and birth d. Developing more positive feelings about her labor and birth

d. Developing more positive feelings about her labor and birth

The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis? a. Prolactin b. Progesterone c. Oxytocin d. Estrogen

d. Estrogen

The nurse is caring for a woman at 28 weeks gestation with a history of preterm delivery. Which of the following laboratory data should the nurse carefully assess in relation to this diagnosis? a. Human relaxin levels b. Amniotic fluid levels c. Alpha-fetoprotein levels d. Fetal fibronectin levels

d. Fetal fibronectin levels

The Apgar score consists of a rapid assessment of five physiological signs that indicate the physiological status of the newborn and includes: a. Apical pulse strength, respiratory rate, muscle flexion, reflex irritability, and color b. Heart rate, clarity of lungs, muscle tone, reflexes, and color c. Apical pulse strength, respiratory rate, muscle tone, reflex irritability, and color of extremities d. Heart rate, respiratory rate, muscle tone, reflex irritability, and color

d. Heart rate, respiratory rate, muscle tone, reflex irritability, and color

Instructions to a mother of an uncircumcised male infant should include which of the following? a. Instruct her to use a cotton swab to clean under the foreskin. b. Instruct her to clean the penis by retracting the foreskin. c. Instruct her to clean the penis with alcohol. d. Instruct her not to retract the foreskin.

d. Instruct her not to retract the foreskin.

A perinatal nurse assesses the skin condition of a newborn, which is characterized by a yellow coloration of the skin, sclera, and oral mucous membranes. What condition is most likely the cause of this symptom? a. Hypoglycemia b. Physiologic anemia of infancy c. Low glomerular filtration rate d. Jaundice

d. Jaundice

A 16-year-old patient is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following? a. High leukocyte count b. Explosive diarrhea c. Fractured pelvis d. Low platelet count

d. Low platelet count

A nurse assesses that a 3-day-old neonate who was born at 34 weeks' gestation has abdominal distention and vomiting. These assessment findings are most likely related to: a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC)

d. Necrotizing Enterocolitis (NEC)

A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see? a. Postpartum hemorrhage b. Neonatal hyperglycemia c. Postpartum oliguria d. Neonatal macrosomia

d. Neonatal macrosomia

A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following? a. Hypoglycemia b. Hypercalcemia c. Cold stress d. Neonatal withdrawal

d. Neonatal withdrawal

The perinatal nurse explains to a student nurse the cardiopulmonary adaptations that occur in the neonate. Which one of the following statements accurately describes the sequence of these changes? a. As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance. b. As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs

d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs

The nurse is massaging a boggy uterus. The uterus does not respond to the massage. Which medication would the nurse expect would be given first: a. Methergine b. Ergotrate c. Carboprost d. Oxytocin or pitocin

d. Oxytocin or pitocin

The perinatal nurse explains to the student nurse that successful cardiopulmonary adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the ________, the ________, and the _________.

foramen ovale; ductus arteriosus; ductus venosus

You are in the process of admitting a multiparous woman to labor and delivery from the triage area. One hour ago her vaginal exam was 4/70/0. While completing your review of her prenatal record and completing the admission questionnaire, she tells you she has an urge to have a bowel movement and feels like pushing. Your priority nursing intervention is to: a. Reassure the patient and rapidly complete the admission. b. Assist your patient to the bathroom to have a bowel movement. c. Assess the fetal heart rate and uterine contractions. d. Perform a vaginal exam.

d. Perform a vaginal exam.

Heat loss through radiation can be reduced by: a. Closing door to room b. Warming equipment used on the neonate c. Drying the neonate d. Placing crib near a warm wall

d. Placing crib near a warm wall

A nurse is admitting a woman for a scheduled cesarean section. Which of the following assessment data should be immediately reported to the physician? a. White cell count of 11,000 b. Hemoglobin of 11 g/dL c. Hematocrit of 33% d. Platelet count of 97,000

d. Platelet count of 97,000

Which of the following statements is most appropriate for the nurse to say to a patient with a complete placenta previa? a. During the second stage of labor you will need to bear down. b. You should ambulate in the halls at least twice each day. c. The doctor will likely induce your labor with oxytocin. d. Please promptly report if you experience any bleeding or feel any back discomfort

d. Please promptly report if you experience any bleeding or feel any back discomfort

A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, closed posterior fontanel, and point of maximum intensity at the xiphoid process. Which of the assessments should be reported to the health-care practitioner? a. Birth weight b. Sagittal suture line c. Closed posterior fontanel d. Point of maximum intensity

d. Point of maximum intensity

The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan? a. Water temperature for the infant's bath should be 39°C. b. Crib slates should be a maximum of 3 inches apart. c. Cover electrical outlets once the infant is crawling. d. Remove strings from infant sleepwear.

d. Remove strings from infant sleepwear.

A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediate intervention? a. Itching of the palms and feet b. Nausea c. Urinary output of 300 mL in the past 4 hours d. Respiratory rate of 10 breaths/minute

d. Respiratory rate of 10 breaths/minute

A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate for this mother? a. Risk for altered parenting b. Risk for imbalanced nutrition: less than body requirements c. Risk for ineffective individual coping d. Risk for fluid volume deficit

d. Risk for fluid volume deficit

Ms. P has delivered her first baby 30 minutes ago and the placenta delivered 15 minutes ago. She is attempting to breastfeed her newborn daughter for the first time. Which action by the nurse would NOT be appropriate? a. The nurse is checking the BP every 15 minutes b. The nurse is massaging the fundus vigorously c. The nurse is auscultating the infants heart and lungs while on the mothers chest d. The nurse is leaving the patient unattended for 30 minutes to bond with her newborn

d. The nurse is leaving the patient unattended for 30 minutes to bond with her newborn

The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption? a. The patient with placenta previa b. The patient whose vagina is colonized with group B streptococci c. The patient who is hepatitis B surface antigen positive d. The patient with eclampsia

d. The patient with eclampsia

__________________ is contraindicated with shoulder dystocia.

fundal pressure Fundal pressure is contraindicated with shoulder dystocia because it mayfurther impact the shoulder and increases risk of fetal injury.

A nurse is making a home visit on the seventh postpartum day to assess a 23-year-old primipara woman and her full-term, healthy baby. Breastfeeding is the method of infant nutrition. The woman tells the nurse that she does not think her milk is good because it looks very watery when she expresses a little before each feeding. The nurse's best response is: a. This is normal. You only have to be concerned when your baby does not gain weight. b. What types of foods are you eating? A lack of protein in the diet can cause watery-looking breast milk. c. How much fluid are you drinking while you are nursing your baby? Too much fluid during the feeding session can dilute the breast milk. d. This is normal and is referred to as foremilk which is higher in water content. Later in the feeding, the fat content increases and the milk becomes richer in appearance.

d. This is normal and is referred to as foremilk which is higher in water content. Later in the feeding the fat content increases and the milk becomesricher in appearance.

Assessment of the infant's anterior fontanel is an important part of the physical examination. The nurse knows that dehydration can cause a _______ in the fontanel and ______ might increase the pressure in the fontanel.

depression; crying

The perinatal nurse recognizes that the laboring multiparous patient who is attempting a vaginal birth following a previous cesarean birth (VBAC) needs frequent assessments to ensure that there is _______ during her labor

progress Women with a previous history of cesarean birth may be offered a trial of labor,although a prompt cesarean birth is recommended at the earliest sign of maternal or fetal compromise.

The perinatal nurse knows that nausea and vomiting are common in pregnancy and usually resolve by ____ weeks gestation. The severe form of this condition is _________

16, hyperemesis gravidarum Nausea and vomiting are a common condition of pregnancy which affect 70% to 85% of pregnant women and usually resolve by the 16th week of gestation. Hyperemesis gravidarum represents the extreme end of the nausea/vomiting spectrum interms of severity. Criteria for the diagnosis of hyperemesis gravidarum include persistent vomiting unrelated to other causes, a measure of acute starvation (usually large ketonuria), and some discrete weight loss, most often 5% of the pre-pregnancy weight.