Postpartum
Baby-friendly hospitals mad ate that infants be put to breast within what time frame of birth?
1 hour
Gestational diabetes is diagnosed at 24-28 weeks after routine screening with a 1 hour GTT. What is the normal result of this lab?
<140
If Debbie was to become a diet controlled diabetic during pregnancy, she what have what type of diabetes?
A1
If Donna becomes diabetic during pregnancy and requires insulin, she would have what type?
A2
What herbal remedy is a commonly used oxytocic agent?
Blue cohosh Blue cohosh, cotton root bark, motherwort, and shepherd's purse are oxytocic agents that promote uterine contraction.
A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?
Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.
PP Vitals
During the first 24 hours postpartum, temperature may increase to 38° C (100.4° F) Pulse, remains elevated for the first hour or so after childbirth. It then begins to decrease to a nonpregnant rate. A rapid pulse may indicate hypovolemia. Respiratory rate is normal. Blood pressure is altered slightly if at all postpartum.
Endometritis
Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth and not limited to first-time mothers.
Proper breastfeeding techniques:
Holding the breast with four fingers along the bottom and the thumb at top is a correct technique. To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. Stimulating the rooting reflex is correct. Placing the finger in the mouth to remove the baby from the breast is correct.
Which action of a breastfeeding mother indicates the need for further instruction?
Leans forward to bring breast toward the baby.
The nurse is caring for an infant who is suspected to have neonatal sepsis. Which neonatal risk factor for an infant with suspected neonatal sepsis would the nurse expect to observe?
Multiple gestation and low birth weight
Labs for preeclampsia
NST, serial BP's, labs
HSV
Neonate effects: skin, mouth, eye lesions; potential damage to nerves or eyes; risk of spreading to brain.
Which findings would be a source of concern if noted at 12 hour PP:
Pain in left calf with dorsiflexion of left foot, (thrombophlebitis) lochia rubra with foul odor (infection)
Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI?
Paroxetine
Maternal and fetal risks when exposed to glucose intolerance:
Polyhydramnios hypertension fetal death cord prolapse UTI's Neonatal respiratory distress syndrome Neonatal polycythemia
What are normal findings 12 hour PP?
Postural hypotension r/t circulatory changes after birth. A temp of 100.4ºF often indicates dehydration. Heart rate of 55 BPM is expected in initial PP period.
Doris: 34, G3P1, Hx of Type 1, one miscarriage, previous LGA baby; what type of diabetes does she have?
Pregestational White's classification: B
As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures
Prevent exposure to people with upper respiratory tract infections, Keep the infant away from secondhand smoke, avoid loose bedding, waterbeds, and beanbag chairs
The patient has increased liver enzymes. Which clinical symptom does the nurse expect to increase in severity?
RUQ pain
Which laboratory test result would be a cause for concern if exhibited by an Rh-positive newborn 12 hours after birth?
Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratories (VDRL): reactive (indicates syphillis)
Severe preeclampsia
Requires hospitalization and treatment with magnesium and antihypertensives
The nurse is caring for an infant born at 28 weeks of gestation. Which complication could the nurse expect to observe during the course of the neonate's hospitalization? (Select all that apply.)
Respiratory distress syndrome Periventricular hemorhage Patent ductus arteriosus
SOFTCHALK STD MATCHING
Rubella: progressive hearing loss Cytomegalovirus: IUGR and microcephaly HSV: disseminated infection requiring IV Acyclovir Parvovirus: 5th disease GBS: antepartum screening and IV PCN usage in labor Chlamydia: neonatal conjuctivitis and pneumonia
What's the worst thing that could happen with preeclamptic patient?
Seizure/stroke
With regard to hemolytic diseases of the newborn, nurses should be aware that:
The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.
A nurse is planning care for a client with an intrauterine fetal demise. Which of the following is an inappropriate goal for this client?
The woman will recognize that thoughts of worthlessness and suicide are normal after a loss.
Which TORCH infection could be contracted by the infant because the mother owned a cat?
Toxoplasmosis
varicella
VZIG
Which statement regarding infant weaning is correct?
Weaning can be mother or infant initiated
You understand the decreased profusion to the kidneys will result in increased excretion of:
albumin
A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae:
are benign if they disappear within 48 hours of birth.
When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:
assist the woman to empty her bladder. A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.
Toxoplasmosis
cat litter, raw meat; "flu"-like symptoms, swollen lymph glands, muscle aches and pains • Maternal effects: asymptomatic, risk for PTL or demise • Neonatal effects: high risk between 10-24w, IUGR, hydro-and microencephaly
syphilis
copper-colored papular dermal rash
What observations do you make when administering MgSO4 and why?
decreased DTR hypotension confusion low body temp headache breathing difficulties
The birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborn's weight was 7 lbs, 12 oz. On the basis of this finding, the nurse should:
encourage the mother to continue breastfeeding since it is effective in meeting the newborn's nutrient and fluid needs. Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz. Breastfeeding is effective at this time. Breastfeeding is effective, and bottle-feeding does not need to be initiated at this time. The infant is not undernourished, and the physician does not need to be notified. The weight loss is within normal limits; breastfeeding is effective.
Vitamin K is given to newborn to:
enhance ability of blood to clot
The priority nursing intervention for a woman who suffered a perineal laceration is to:
establish homeostasis
Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to:
expect a yellowish exudate to cover the glans after the first 24 hours.
The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by:
explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.
gonorrhea
eye prophylaxis
With regard to the classification of neonatal bacterial infection, nurses should be aware that:
health care-associated infection can be prevented by effective handwashing; early onset cannot.
Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect
hematoma formation.
An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:
hypoglycemia The tremors are jitteriness that is associated with hypoglycemia.
A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action is to:
listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.
The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:
palpate uterus and massage it if it is boggy
If labs are normal?
patient will go home on bed rest with follow up NST in three days.
Complications of post maturity:
polycythemia, meconium aspiration syndrome, and persistent pulmonary hypertension
When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should:
prewarm the radiant heat warmer and place the undressed newborn under it
The cremasteric reflex
refers to retraction of testes when chilled.
Tonic neck reflex
refers to the "fencing posture" a newborn assumes when supine and turns the head to the side.
The Babinski reflex
refers to the flaring of the toes when the sole is stroked.
Bladder distention
results in an elevation of fundus above umbilicus and deviation to right or left of midline
A newborn male, estimated to be 39 weeks of gestation, would exhibit:
testes descended into scrotum The newborn's good muscle tone will result in a more flexed posture when at rest. A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would have the inability to move his elbow past midline.
With regard to umbilical cord care, nurses should be aware that:
the stump can easily become infected.
HIV
this positive mother should not breastfeed in the US
Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:
use a rear-facing car seat
Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present at birth, although they may not be diagnosed immediately. The most common type of CHD is:
ventricular septal defect (VSD)
A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is:
vision. The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.
In helping the breastfeeding mother position the baby, nurses should keep in mind that:
whatever the position used, the infant is "belly to belly" with the mother.
Insulin needs throughout pregnancy
1st Trimester: decrease, glucose shift and N/V 2nd Trimester: increased need due to resistance from hormones and increased fetal needs for glucose 3rd Trimester: increased need due to hormones and fetal needs PP: decreased need, placental hormones changing
A nurse is teaching umbilical cord care to a new mother. The nurse tells the mother that: 1 Alcohol is the only agent to use to clean the cord. 2 Cord care is done only at birth to control bleeding. 3 It takes at least 21 days for the cord to dry up and fall off. 4 The process of keeping the cord clean and dry will decrease bacterial growth.
Answer: 4 Rationale: The cord should be kept clean and dry to decrease bacterial growth. It should be cleansed two to three times a day using alcohol or other agents. Cord care is required until the cord dries up and falls off between 7 and 14 days after birth. Additionally, the diaper should be folded below the cord to keep urine away from the cord. Priority Nursing Tip: Teach the mother to keep the newborn's diaper from covering the cord . The diaper should be folded below the cord.
Storage of breast milk:
Breast milk storage guidelines for home use for full-term infants are: Before expressing or pumping breast milk, wash your hands. Containers for storing milk should be washed in hot, soapy water and rinsed thoroughly; they can also be washed in a dishwasher. If the water supply may not be clean, boil containers after washing. Plastic bags designed specifically for breast milk storage can be used for short-term storage (<72 hours). Write the date of expression on container before storing milk. A waterproof label is best. Store milk in serving sizes of 2 to 4 ounces to prevent waste. Storing breast milk in the refrigerator or freezer with other food items is acceptable. When storing milk in a refrigerator or freezer, place containers in the middle or back of the freezer, not on the door. When filling a storage container that will be frozen, fill only three quarters full, allowing space at the top of the container for expansion. To thaw frozen breast milk, place container in the refrigerator for gradual thawing or under warm, running water for quicker thawing. Never boil or microwave. Milk thawed in the refrigerator can be stored for 24 hours. Thawed breast milk should never be refrozen. Shake milk container before feeding baby and test the temperature of the milk on the inner aspect of your wrist. Any unused milk left in the bottle after feeding is discarded.
TORCH
Toxoplasmosis Other (Hep B) Rubella (German Measles) Cytomegalovirus (CMV) Herpes Simplex Virus (HSV)
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include:
abdominal distention, temperature instability, and grossly bloody stools.
In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:
alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.
An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver:
alerts the physician that the infant has a dislocated hip.
Postbirth uterine/vaginal discharge, called lochia:
should smell like normal menstrual flow unless an infection is present. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with ambulation and breastfeeding. An offensive odor usually indicates an infection.
The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:
wear a snug, supportive bra. A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking.
When weighing a newborn, the nurse should:
weigh the newborn at the same time each day for accuracy The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.
The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a:
Moro reflex
Cytomegalovirus (CMV)
Most common congenital infection at birth in U.S.; IUGR, microcephaly, CNS abnormalities, hydrocephaly, per ventricular calcification, deafness, bindles, mental retardation.
A 10-day postpartum breast-feeding client telephones the postpartum unit complaining of a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, the nurse tells the client to:
" Notify your physician because you may need medication." Rationale: Based on the signs and symptoms presented by the client (particularly the elevated temperature), the physician needs to be notified because an antibiotic that is tolerated by the infant as well as the mother may be prescribed. The mother should continue to nurse on both breasts , but should start the infant on the unaffected breast while the affected breast lets down.
A rubella vaccine is administered to a client who delivered a healthy newborn infant 2 days ago. The nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?
"I need to prevent becoming pregnant for 2 to 3 months after the vaccination." Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward.
Acidification of urine
Acidification of the urine inhibits the multiplication of bacteria. Fluids that acidify the urine include apricot, prune, and cranberry juice. Carbonated drinks should be avoided, because they increase urine alkalinity.
What measures can be taken to prevent postpartum hemorrhage?
Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.
A nurse in the postpartum unit is caring for a mother after vaginal delivery of a healthy newborn infant. The client received epidural anesthesia for the delivery. One-half hour after admission to the postpartum unit, the nurse checks the client and suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma? 1 Changes in vital signs 2 Signs of vaginal bruising 3 Client complaints of a tearing sensation 4 Client complaints of intense vaginal pressure
Answer: 1 Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Because the client received anesthesia, she would not feel pain or pressure . Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma. Priority Nursing Tip: Monitor the postpartum client for abnormal pain or perineal pressure, especially when forceps delivery has occurred.
A physician has written a prescription to administer methylergonovine maleate (Methergine) to a postpartum client with uterine atony. The nurse would contact the physician to verify the prescription if which of the following conditions were present in the mother? 1 Hypertension 2 Excessive lochia 3 Difficulty locating the uterine fundus 4 Excessive bleeding and saturation of more than one peripad per hour
Answer: 1 Rationale: Methylergonovine maleate (Methergine) is an ergot alkaloid. It is contraindicated for the hypertensive woman, individuals with severe hepatic or renal disease, and during the third stage of labor. Excessive lochia, a uterine fundus that is difficult to locate, and excessive bleeding are clinical manifestations of uterine atony indicating the need for methylergonovine. Priority Nursing Tip: Methylergonovine maleate (Methergine) is an ergot alkaloid that produces vasoconstriction. The client's blood pressure needs to be monitored closely and if an increase is noted the medication is withheld and the physician is notified.
It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted: 1 At the level of the umbilicus 2 One finger breadth below the umbilicus 3 Two finger breadths below the umbilicus 4 Midway between the umbilicus and the symphysis pubis
Answer: 1 Rationale: The term "involution" is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its nonpregnant state. Immediately after the delivery of the placenta, the uterus contracts to the size of a large grapefruit . The fundus is situated in the midline between the symphysis pubis and the umbilicus. Within 6 to12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one finger breadth on each succeeding day. Priority Nursing Tip: By approximately 10 days postpartum, the uterus cannot be palpated abdominally.
A nurse teaches a postpartum client about observation of lochia. The nurse determines the client's understanding when the client says that on the second day postpartum , the lochia should be: 1 Red 2 Pink 3 White 4 Yellow
Answer: 1 Rationale: The uterus rids itself of the debris that remains after birth through a discharge called "lochia," which is classified according to its appearance and contents. Lochia rubra is dark red in color. It occurs from delivery to 3 days postpartum and contains epithelial cells, erythrocytes, leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia serosa is a brownish pink discharge that occurs from days 4 to 10. Lochia alba is a white discharge that occurs from days 10 to 14. Lochia should not be yellow in color or contain large clots; if it does, the cause should be investigated without delay. Priority Nursing Tip: The amount of lochial discharge may increase with ambulation.
A nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago and notes that the mother's temperature is 102 ° F. The appropriate nursing action would be to: 1 Notify the physician. 2 Remove the blanket from the client's bed. 3 Document the finding and recheck the temperature in 4 hours. 4 Administer acetaminophen (Tylenol) and recheck the temperature in 4 hours.
Answer: 1 Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102 ° F indicates infection, and the physician should be notified. Options 2 , 3, and 4 are inaccurate nursing interventions for a temperature of 102 ° F 2 hours after delivery. Priority Nursing Tip: A temperature of 100.4 ° F is normal during the first 24 hours postpartum because of dehydration, a temperature of 100.4 ° F or greater after 24 hours postpartum indicates infection.
A nurse in the postpartum unit is assessing a newborn infant for signs of breastfeeding problems. Which of the following indicates a problem? Select all that apply. 1 The infant exhibits dimpling of the cheeks. 2 The infant makes smacking or clicking sounds. 3 The mother's breast gets softer during a feeding. 4 Milk drips from the mother's breast occasionally. 5 The infant falls asleep after feeding less than 5 minutes. 6 The infant can be heard swallowing frequently during a feeding.
Answer: 1, 2, 5 Rationale: It is important for the nurse to identify breast-feeding problems while the mother is hospitalized so that the nurse can teach the mother how to prevent and treat any problems. Infant signs of breastfeeding problems include dimpling of the cheeks; making smacking or clicking sounds; falling asleep after feeding less than 5 minutes; refusing to breastfeed; tongue thrusting; failing to open the mouth at latch-on; turning the lower lip in; making short, choppy motions of the jaw; and not swallowing audibly. Softening of the breast during feeding, noting milk in the infant's mouth or dripping from the mother's breast occasionally, and hearing the infant swallow are signs that the infant is receiving adequate nutrition. Priority Nursing Tip: If the mother is breast-feeding, calorie needs increase by 200 to 500 calories per day; increased fluids and the continuance of prenatal vitamins and minerals are important.
Methylergonovine (Methergine) is prescribed for a woman who has just delivered a healthy newborn infant . The priority assessment before administering the medication is to check the client's: 1 Lochia 2 Uterine tone 3 Blood pressure 4 Deep tendon reflexes
Answer: 3 Rationale: Methergine, an oxytocic , is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine is blood pressure. Methylergonovine is to be administered cautiously in the presence of hypertension, and the physician should be notified if hypertension is present.
A woman in labor and delivery was given a spinal anesthesia for her scheduled caesarean delivery. The next day she presses her call light and tells the nurse she has a terrible headache. Put the following actions in priority order. (Number 1 is the first action and number 5 is the last action.) ___Review the labor and delivery record. ___Assess her blood pressure and heart rate. ___Assess her pain scale using the numeric pain scale. ___Give the woman caffeine in the form of a liquid drink. ___Determine the effectiveness of the caffeine after 1 hour.
Answer: 1, 3, 2, 4, 5 Rationale: A spinal headache sometimes occurs 24 hours after the spinal catheter is removed. Injecting preservative-free saline through the catheter before removing it may decrease the possibility of a headache. Conservative treatment for the headache is oral analgesics, caffeine, or theophylline. The first step is to always review the labor and delivery record to determine if any treatment was administered and then continue with the nursing process. The nurse would assess the degree of pain and then assess vital signs for abnormalities before treating the client. The nurse would administer the caffeine and then evaluate the effect of the treatment. Priority Nursing Tip: A spinal headache is treated conservatively at first with caffeine because caffeine can cause vasoconstriction of cerebral blood vessels and provide symptomatic relief.
A postpartum nurse has instructed a new mother regarding how to bathe her newborn infant. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly? 1 The mother cleans the ears and then moves to the eyes and the face. 2 The mother begins to wash the newborn infant by starting with the eyes and face. 3 The mother washes the arms, chest, and back followed by the neck, arms, and face. 4 The mother washes the entire newborn infant's body and then washes the eyes, face, and scalp.
Answer: 2 Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The newborn infant's neck should be washed, because formula, lint, and breast milk will often accumulate in the folds of the neck. The hands and arms are then washed. The newborn infant's legs are washed next, with the diaper area being washed last.
A nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of the care required? 1 " I need to clean the penis every hour with baby wipes." 2 "I need to check for bleeding every hour for the first 12 hours." 3 "My baby will not urinate for the next 24 hours because of swelling." 4 " I need to wrap the penis completely in dry sterile gauze, making sure that it is dry when I change his diaper."
Answer: 2 Rationale: Following circumcision, the mother needs to be taught to observe for bleeding and assess the site hourly for 8 to 12 hours. Voiding needs to be assessed. The mother should call the physician if the baby has not urinated within 24 hours, because swelling or damage may obstruct urine output. When the diaper is changed, Vaseline gauze should be reapplied (if prescribed). Frequent diaper changing prevents contamination of the site. Water is used for cleaning, because soap or baby wipes may irritate the area and cause discomfort. Priority Nursing Tip: The nurse should inform the parents that a milky covering over the glans penis is normal and should not be disrupted.
A nurse is performing an assessment on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note that the fundus is positioned: 1 To the right of the abdomen 2 At the level of the umbilicus 3 Above the level of the umbilicus 4 One fingerbreadth above the symphysis pubis
Answer: 2 Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus need to be expelled by fundal massage. A fundus that is not located in the midline may indicate a full bladder. Priority Nursing Tip: The postpartum period starts immediately after delivery and is usually completed by week 6 after delivery.
A nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she breast-feeds for the first time and intervenes if the new mother: 1 Turns the newborn infant on his side, facing the mother 2 Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth 3 Draws the newborn the rest of the way onto the breast when the newborn opens his mouth 4 Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast Silvestri, Linda Anne (2011-11-23). Saunders Q&A Review for the NCLEX-RN® Examination (Saunders Q&A Review for NCLEX-RN) (Kindle Locations 14913-14919). Elsevier Health Sciences. Kindle Edition.
Answer: 2 Rationale: The mother is instructed to avoid tilting up the nipple or squeezing the areola and pushing it into the newborn's mouth; doing so does not facilitate the breast-feeding process or the flow of milk. Priority Nursing Tip: A breast-fed infant's stools are usually light yellow, seedy, watery, and frequent.
A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk to the client, the nurse recognizes that the client needs to work through which emotion before maternal bonding can occur? 1 Guilt 2 Grief 3 Anger 4 Depression
Answer: 2 Rationale: The mother must first be assisted to grieve for the anticipated perfect child that she did not have. After this is accomplished , the mother can begin to focus on bonding with the infant to whom she did give birth.
A nurse is preparing to care for the mother of a preterm infant. The nurse plans to begin discharge planning: 1 When the mother is in labor 2 When the discharge date is set 3 After stabilization of the infant during the early stages of hospitalization 4 When the parents feel comfortable with and can demonstrate adequate care of the infant
Answer: 3 Rationale: Discharge planning begins at admission. The determination of the services, needs, supplies, and equipment requirements should not be made on the day of discharge.
A nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially? 1 Notify the physician. 2 Encourage the mother to ambulate. 3 Massage the fundus gently until it is firm. 4 Document fundal position, consistency, and height.
Answer: 3 Rationale: If the fundus is boggy (soft), it should be massaged gently until it is firm and the client is observed for increased bleeding or clots. Option 2 is an inappropriate action at this time. The nurse should document the fundal position, consistency, and height; the need to perform fundal massage; and the client's response to the intervention. The physician will need to be notified if uterine massage is not helpful. Priority Nursing Tip: The nurse needs to gently massage the fundus of a client experiencing uterine atony and take care not to overmassage.
A postpartum client with gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, "Do I have to worry about this diabetes anymore?" Which of the following is the appropriate response by the nurse? 1 "Your blood glucose level is within normal limits now, so you will be all right." 2 "You will only have to worry about the diabetes if you become pregnant again." 3 "You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus." 4 "When you have gestational diabetes, you have diabetes forever, and you must be treated with medication for the rest of your life."
Answer: 3 Rationale: The client is at risk for developing gestational diabetes with each pregnancy . The client also has an increased risk for developing diabetes mellitus and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for developing diabetes mellitus, such as weight control. The diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing diabetes mellitus ; however , with proper care, it may not develop. Priority Nursing Tip: Pregnant women should be screened for gestational diabetes between 24 and 28 weeks of pregnancy. Oral hypoglycemic agents are never prescribed for use during pregnancy.
A mother who is breast-feeding her newborn infant is experiencing nipple soreness, and the nurse provides instructions regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the instructions? 1 "I need to avoid rotating breast-feeding positions so that the nipple will toughen." 2 "I need to stop nursing during the period of nipple soreness to allow the nipples to heal." 3 "I need to nurse less frequently and substitute a bottle feeding until the nipples become less sore." 4 "I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me."
Answer: 4 Rationale: Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant's stomach against the mother's. Additional measures include rotating breast-feeding positions; breaking suction with the little finger; nursing frequently; beginning feeding on the less sore nipple; not allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth; and applying tea bags soaked in warm water to the nipple. Priority Nursing Tip: The nurse needs to assess the newborn's ability to attach to the mother's breast and suck.
A nurse determines that a client is beginning to experience shock and hemorrhage as a result of a partial inversion of the uterus. The nurse pages the obstetrician to come immediately and calls for assistance. The client asks in an apprehensive voice, "What is happening to me? I feel so funny, and I know I'm bleeding . Am I dying?" The nurse responds to the client, knowing that the client is feeling: 1 Panic as a result of shock 2 Anticipatory grieving related to the fear of dying 3 Depression related to postpartum hormonal changes 4 Fear and anxiety related to unexpected and ambiguous sensations
Answer: 4 Rationale: Feelings of loss of control are common causes of anxiety, and the unknown is the most common cause of fear. Apprehension and feelings of impending doom are also associated with shock, but the information in the question does not suggest panic at this point. Anticipatory grieving occurs when there is knowledge of the impending loss, but it is not associated with a sudden situational crisis such as this one. It is far too early for the onset of postpartum depression. Priority Nursing Tip: For the postpartum client experiencing uterine atony, the nurse should massage the fundus, taking care not to over massage. If the client is hemorrhaging, the nurse should remain with the client and ask another nurse to contact the physician.
After delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or when she plans to care for her newborn infant. The nurse informs the client that this is necessary to: 1 Help the mother assume the parenting role. 2 Minimize the potential of postpartum hemorrhage. 3 Provide an opportunity for the nurse to teach newborn infant care techniques. 4 Avoid maternal or infant injury caused by the potential for syncope or overexertion.
Answer: 4 Rationale: The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Priority Nursing Tip: Monitor the postpartum client with cardiac disease closely for signs and symptoms of cardiac stress and decompensation. These include cough, fatigue, dyspnea, chest pain, and tachycardia.
A nurse is caring for a postpartum client with thromboembolytic disease. When planning care to prevent the complication of pulmonary embolism, the nurse plans specifically to: 1 Enforce bedrest. 2 Monitor the vital signs frequently. 3 Assess the breath sounds frequently. 4 Administer and monitor anticoagulant therapy as prescribed.
Answer: 4 Rationale: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. prevention of pulmonary embolism. Priority Nursing Tip: Medications containing aspirin should not be given to clients receiving anticoagulant therapy, because aspirin prolongs the clotting time and increases the risk of bleeding.
A nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal would be most appropriate for this client? 1 The client will verbalize a reduction of pain. 2 The client will report how to treat an infection. 3 The client will be able to identify measures to prevent infection. 4 The client will identify the presence of Braxton Hicks contractions.
Answer: 4 Rationale: The uterus is theoretically sterile during pregnancy until the membranes rupture. However, it is capable of being invaded by pathogens after membrane rupture. Priority Nursing Tip: In the postpartum client, a temperature of 100.4 ° F or greater after 24 hours postpartum indicates infection.
A new breast -feeding mother is seen in the clinic with complaints of breast discomfort . The nurse determines that the mother is experiencing breast engorgement and provides the mother with instructions regarding care for the condition. Which statement by the mother indicates an understanding of the measures that will provide comfort for the engorgement? 1 "I will breast -feed using only one breast." 2 "I will apply cold compresses to my breasts." 3 "I will avoid the use of a bra while my breasts are engorged." 4 "I will massage my breasts before feeding to stimulate letdown."
Answer: 4 Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown; wearing a supportive well-fitting bra at all times; taking a warm shower or applying warm compresses just before feeding; and alternating the breasts during feeding. Priority Nursing Tip: The postpartum client who is breast-feeding should not use soap on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples.
What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?
Apical heart rate of 90 beats/min, slightly irregular, when awake and active The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.
Cultural considerations regarding Pregnancy:
Asian mothers must remain at home with the baby up to 30 days after birth and are not supposed to engage in household chores, including care of the baby. Jordanian mothers have a 40-day lying-in after birth, during which their mothers or sisters care for the baby. Japanese mothers rest for the first 2 months after childbirth. Hispanic practice involves many food restrictions after childbirth, such as avoiding fish, pork, and citrus foods. Vietnamese mothers may give minimal care to their babies and refuse to cuddle or further interact with the baby to ward off "evil" spirits.
Administer IV bolus dose of 4 gm Mag sulfate over 30 min. Following bolus dose, a continuous infusion is to run at 2 gm/hour. The IV bag contains mag sulfate 40 gm in 500 mL NS. How would you set the pump to deliver bolus dose? At what rate would you run the continuous infusion?
Bolus dose: VTBI 50 mL at rate of 100 mL/hr Rate for continuous infusion: 25 mL/hr
A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:
Excessive uterine bleeding. Excessive bleeding can occur immediately after birth if the bladder becomes distended, because it pushes the uterus up and to the side and prevents it from contracting firmly. A ruptured bladder may result from a severely overdistended bladder.
Your patient is hyperreflexic with clonus. Clonus is:
Fasciculations after dorsiflexion of the foot
3 hour GTT normal values
Fasting: 1-hour: 2-hour: 3-hour:
Rubella
German measles, rash, swollen glands; Fetal effects-blindness, cataracts, hearing loss, heart defects, mental retardation, movement disorders, DM
Which PP conditions are considered medical emergencies that require immediate treatment?
Inversion of the uterus and hypovolemic shock.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:
Massage the woman's fundus. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from an impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.
Which PP infection is most often contracted by first-time mothers who are breastfeeding?
Mastitis Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding.
Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care?
PPD can easily go undetected.
Which description of postpartum restoration or healing times is accurate?
Rugae reappear within 3 to 4 weeks. The cervix regains its form within days; the cervical os may take longer. Rugae are never again as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function resumes. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.
Thromboembolic conditions that are concern during PP period include:
Superficial venous thrombosis DVT Pulmonary embolism
Perineal care is an important infection control measure. Describe methods of perineal care:
Use soap and warm water. Change pad every 2-3 hours. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.
Newborn reflexes:
When eliciting rooting reflex, the characteristic response is for the baby to turn head toward stimulus and open mouth. The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex. Extrusion is elicited by touching tongue, and newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers form a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe.
Wound infections
also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:
cleanse eyes from inner to outer canthus before administration. Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.
Excessive blood loss after childbirth can have several causes; however, the most common is:
failure of the uterine muscle to contract firmly.
With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that
fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Excess fluid loss through other means occurs as well. Bladder tone usually is restored 5 to 7 days after childbirth.
Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects:
hematoma formation. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.
When caring for a newborn, the nurse must be alert for signs of cold stress, including:
increased respiratory rate. Infants experiencing cold stress would have an increased activity level. An increased respiratory rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.
As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1-day postpartum. Expected findings include:
little if any change. Breasts are essentially unchanged for the first 24 hours after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth. Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used. Colostrum, or early milk, a clear, yellow fluid, may be expressed from the breasts during the first 24 hours.
Patient complains of RUQ pain, what do you expect to be ordered?
liver function test
Hep B Virus
malformations, stillbirths, IUGR, and PTL; heatomegaly, malaise; Maternal effects-PTL, cirrhosis, liver CA • Fetal effects- stillbirth
The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:
massage her fundus. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.
With regard to afterbirth pains, nurses should be aware that these pains are
more noticeable in births in which the uterus was over distended. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large baby or multiple babies overdistend the uterus. Breastfeeding intensifies afterbirth pain because it stimulates contractions.