Prep U rationales: Test #2

In completing the newborn assessment checklist, the nurse documents a meconium stool. This documentation rules out which condition?

imperforate anus; Clinical manifestations of an imperforate anus include not having a meconium stool within the first 24 hours of birth.

During the newborn examination, the nurse would suspect spina bifida occulta if what finding is present?

-discolored skin at the base of spine -a dimpling at the base of spine -abnormal tufts of hair at the base of spine

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000 mL; Postpartum hemorrhage is defined as blood loss of 500 mL or more after a vaginal birth and 1000 ml or more after a cesarean birth.

infants in a cast

must have stimulation by contact and play. They have limited ability to move. The best type of play for this age is a mobile that they can look at or a hand toy such as a rattle. The infant is unable to play with baskets and soft balls or books and crayons. The infants can hear musical instruments.

A newly born infant with an Apgar assessment of 5 has made no respiratory efforts despite continuous stimulation. Which actions would the nurse prioritize?

-Begin resuscitation until the newborn has a pulse above 100 bpm. -Continue resuscitation efforts until the newborn adequately breathes. -Perform resuscitation until the newborn has a pink tongue. -Continue resuscitation and provide support to the parents.

The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?

30 to 60 minutes after birth.

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day?

650 calories; Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

A newborn is born diagnosed with an omphalocele. What will the nurse prioritize in the care plan during the preoperative period?

Nursing management of newborns with omphalocele must focus on preventing hypothermia, maintaining perfusion to the eviscerated abdominal contents by minimizing fluid loss, and protecting the exposed abdominal contents. This can be accomplished by placing the infant in a sterile bowel bag that maintains a sterile environment for the exposed contents, allows visualization, reduces heat and moisture loss. The infant may be cared for in an isolette, but a sterile bowel bag is the key to care.

Ovulation may return

as soon as 3 weeks after birth; The client needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

check the lochia; The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion.

For which potential neonatal infection does the nurse anticipate using ophthalmic erythromycin?

clamydia trachomatis; Ophthalmic erythromycin is routinely provided to the newborn after birth to prevent acquiring a Chlamydia trachomatis or Neisseria gonorrhoeae infection during vaginal birth. IV antibiotics are used to treat a Group B streptococcus infection. Antiviral therapy is given to neonates with herpes simplex and human immunodeficiency virus.

During a routine assessment the nurse notes the client is tachycardic. Which possible cause should be ruled out?

delayed hemorrhage; Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications.

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?

difficult to separate clots. If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?

hypovolemia; The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements.

Involution

is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs.

A client with group AB blood whose husband has group O blood has just given birth. Which complication or test result is a major sign of ABO blood incompatibility that the nurse should look for when assessing this neonate?

jaundice within the first 24 hours of life.

A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury

place the newborn in prone or lateral position; The nurse should place the newborn in a prone or lateral position to keep pressure off the spinal sac and avoid newborn injury. Parents should be allowed to hold the stable infant with assistance. The spinal sac should be kept covered and moist until surgery to avoid rupture. Collecting urine decreases the risk of urine stasis, which is sometimes common in spinal defects.

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?

policies that discourage unwrapping and exploring the infant; Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience?

postpartum baby blues; It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:

pulmonary embolism.

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?"

saturating 1 pad in 1 hour; Bleeding is considered heavy when a woman saturates a sanitary pad in 1 hour. Excessive bleeding occurs when a postpartum client saturates 1 pad in 15 minutes. Moderate bleeding occurs when the bleeding saturates less than 15 cm of a pad in 1 hour.

Coital discomfort and localized dryness

usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse.

The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?

uterine atony; Early postpartum hemorrhage usually results from one of the following conditions: uterine atony, lacerations, or hematoma. Most cases of early postpartum hemorrhage result from uterine atony, which is due to the uterine muscles remaining relaxed and not contracting as they should.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg; Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments?

vital signs, pain level and head to toe assessment.

A postpartal woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?

wash her perineum daily with a shower; A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement?

"I might feel like laughing one minute and crying the next."

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder.

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:

"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." Diaphoresis often occurs in postpartum women as a way to get rid of both excess water and waste through the skin. It is not uncommon for a woman to wake up drenched in sweat during the first few days following delivery. This is a normal finding and is not a cause for concern.

What intervention would the nurse recommend for a new breastfeeding mother with mastistis? Select all that apply.

-Begin feedings on the unaffected breast. -Take prescribed antibiotics for 10 days. -Apply warm compresses as a comfort measure for her pain. A woman with mastitis is encouraged to continue breastfeeding her infant, and it is recommended to breastfeed every 90 minutes to 2 hours. Application of warm compresses helps reduce the discomfort of the infection and encourage healing. Prescribed antibiotics are taken for 10 days, and the client is encouraged to complete the regimen. It may also be more comfortable to begin feedings on the unaffected breast, as the vigorous sucking initially may be very painful.

The nurse in the neonatal intensive care unit is caring for a neonate suspected to be at risk for an intraventricular hemorrhage (IVH). Which nursing actions are appropriate?

-Maintain a flexed position of the neonate. -Administer fluids slowly. -Assess for bulging fontanel. -Measure head circumference daily.

The nurse is caring for a newborn who is large for gestational age. Which characteristics are documented as a contributing factor?

-The mother has had previous large for gestational age neonates. -The mother is a poorly controlled diabetic. -Both parents are of a larger stature and size.

A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group.

-commmitment, attachment, and preparation for an infant -acquaintance with and increasing attachment to the infant -moving toward a new normal routine -achievement of the parental role

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

100.4° F (38° C).

Lochia flow

A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

The nurse observes an ambulating postpartal woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?

Assess for warmth, erythema, and pedal edema.

Congenital disorders

All congenital disorders are not diagnosed at birth. Hydrocephalus is one such disorder that may be diagnosed at birth but also may not be diagnosed until after a few weeks or months. It is also true that congenital defects may be caused by both genetics and environmental factors.

The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant?

Creases covering two-thirds of the anterior foot.

The parent has brought a 2-year-old to the public clinic for immunizations. The nurse documents the following characteristics: A duck waddle gait Shortened extremity Asymmetry of the gluteal folds Protruding abdomen The nurse then refers the toddler to the health care provider for potential diagnosis of which?

Developmental dysplasia of the hip; Developmental dysplasia of the hip (DDH) exhibits signs of asymmetry of the gluteal folds, lordosis, swayback, protruding abdomen, shortened extremity, and a duck-like waddle. Congenital talipes equinovarus is clubfoot. Scoliosis is a curvature of the spine. Muscular dystrophy is a chronic degenerative muscular condition.

A postpartal woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf; A positive Homans' sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for reddness and warmth and if she has increased pain when she ambulates or bears weight.

Letting-go phase

During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent.

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply.

Edema and slight bruising; During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness, bleeding or discharge.

The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration?

Engorgement; The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. Mastitis or blocked milk ducts do not typically develop until there is fully established breastfeeding.

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition?

Expiratory grunting, a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression from mild-to-severe respiratory distress, intercostal retractions, cyanosis, surfactant dysfunction, airway obstruction, hypoxia, and chemical pneumonitis with inflammation of pulmonary tissues are seen in a newborn with meconium aspiration syndrome.

Negative attachment

Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify?

Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta.

Fetal alcohol syndrome

Fetal alcohol syndrome is one of the most common known causes of intellectual disability. The newborn is also at risk for fetal alcohol spectrum disorder and other alcohol-related birth defects.

Hemolytic disease

Hemolytic disease today is principally the result of ABO incompatibility. The most common incompatibility in the newborn occurs between a woman with type O blood and an infant with type A or B blood.

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?

In the preoperative period, the infant care is focused on protecting the exstrophied bladder and preventing infection. The infant is kept in a supine position, and the bladder is kept moist and covered with a sterile plastic bag. Change soiled diapers immediately to prevent contamination of the bladder with feces. Sponge-bathe the infant only rather than immersing him or her in water to prevent pathogens in the bath water from entering the bladder. Consult the ostomy nurse if necessary.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

Infection.

Which teaching is most helpful in preventing Sudden Infant Death Syndrome (SIDS)?

It is most important to instruct new parents and families to place the infant on his or her back to sleep. Research has shown that this one step has decreased the SIDS rate. It is important to burp an infant after feeding to promote gastrointestinal health. Stuffed animals should not be placed in the crib. Many families use a nursery monitor but that is not helpful in preventing SIDS.

Which nursing actions limit overstimulation of the preterm infant?

It is noted that excessive noise can overstimulate the preterm infant. It is up to the nurse to protect the neurologic status of the infant. Minimize overstimulation by speaking softly to the infant and keeping the lights in the nursery low. Also, coordinate nursing care to minimize interruptions.

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

Lochia rubra is red; it lasts for the first few days of the postpartal period.

While caring for a neonate of a diabetic mother, the nurse should monitor the neonate for which complication?

Neonates of diabetic mothers are at increased risk for macrosomia (excessive fetal growth) due to the increased supply of maternal glucose combined with an increase in fetal insulin. Along with macrosomia, neonates of diabetic mothers are at risk for respiratory distress syndrome, hypoglycemia, hypocalcemia, hyperbilirubinemia, and congenital anomalies.

Which nursing measure is most effective in reducing newborn infections?

Nurses possess the education and assessment tools to decrease the incidence of and reduce the impact of newborn infections. Nurses should implement measures for prevention and early recognition, including maintaining medical and surgical asepsis for all providing care. Nurses should outline and carry out measures to prevent hospital-acquired infections, such as thorough hand-washing hygiene for all staff.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness; A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

Which intervention is helpful for the neonate experiencing drug withdrawal?

Place the Isolette in a quiet area of the nursery. Neonates experiencing drug withdrawal commonly have sleep disturbance. The neonate should be moved to a quiet area of the nursery to minimize environmental stimuli. Medications, such as phenobarbital and paregoric, should be given as needed. The neonate should be swaddled to prevent him from flailing and stimulating himself.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?

Prevent aspiration by elevating the head of the bed, and insert an NG tube to low suction. Documenting the amount and color of drainage is not needed with the NG tube in place. An infant with esophageal atresia is NPO and fed nothing until after repairing the defect. Administering antibiotics and total parenteral nutrition is a postoperative nursing intervention when caring for a newborn with esophageal atresia.

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be most beneficial in treating this client?

Provide oxygen by hood or ventilator; The infant's physical environment should be warm, not cool, and stimulation should be limited for these clients.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing; Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

Which maternal screening during pregnancy indicates the possibility of Down syndrome?

Screening for Down syndrome may begin at 15 weeks' gestation for low maternal serum AFP levels and high chorionic gonadotropin levels, which indicate the possibility of Down syndrome in the fetus. Amniocentesis and chorionic villus sampling are more accurate.

Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?

Symptoms include fever, chills, malaise, and localized breast tenderness; Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

An infant's nursing diagnosis is "Risk for ineffective gas exchange related to displaced bowel." Which finding would indicate to the nurse that the interventions are effective?

The baby appears stabilized with PO2 over 40 mm Hg, PO2 under 60 mm Hg, and pulmonary artery pressure at baseline level.

Spina bifida with myelomeningocele

The neonate shown was born with spina bifida myelomeningocele, which is a sac containing the spinal cord and meninges with nerves roots embedded in the wall.

Which health care provider assessment technique does the nurse anticipate being used to determine developmental dysplasia of the hip (DDH) on a newborn?

The nurse anticipates that a Barlow sign and Ortolani assessment will be done by an experienced health care provider when the newborn is in the nursery. This includes range of motion of the hip.

The nurse is caring for a neonate in the newborn nursery with congenital talipes equinovarus (bilateral clubfoot). If nonsurgical treatment is chosen, which nursing action is anticipated?

The nurse is caring for a neonate with congenital talipes equinovarus or bilateral club foot. If nonsurgical treatment is chosen, the nurse action anticipated would be holding the feet and ankles in the position determined by the health care provider for casting. Serial casting over time will provide the appropriate correction. Ace wraps will not maintain the intended position. Corrective shoes alone do not change the position of the feet and ankle.

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?

The nurse should know that the infant's mother more than likely was a diabetic. The large size of the infant born to a diabetic mother is secondary to exposure to high levels of maternal glucose crossing the placenta into the fetal circulation. Common problems among infants of diabetic mothers include macrosomia, respiratory distress syndrome, birth trauma, hypoglycemia, hypocalcemia and hypomagnesemia, polycythemia, hyperbilirubinemia, and congenital anomalies. Listlessness is also a common symptom noted in these infants.

A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression?

The symptoms of postpartum depression will last longer and are different than the baby blues. Some signs and symptoms of depression include feeling the following: restless, worthless, guilty, hopeless, moody, sad, and overwhelmed.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?

To check for postpartum hemorrhage; If a new mother is going to hemorrhage, it will usually occur within the first hour following delivery. Therefore, the nurse checks on the client every 15 minutes, noting fundal firmness and position, amount and character of lochia and checking for bladder distension.

Which respiratory disorder in a neonate is usually mild and runs a self-limited course?

Transient tachypnea; Transient tachypnea has an invariably favorable outcome after several hours to several days. The outcome of pneumonia depends on the causative agent involved and may have complications. Meconium aspiration, depending on severity, may have long-term adverse effects. In persistent pulmonary hypertension, mortality is more than 50%.

A 36-week neonate born weighing 1,800 g has microcephaly and microophthalmia. Based on these findings, which risk factor might be expected in the maternal history?

Use of alcohol; The most common sign of the effects of alcohol on fetal development is retarded growth in weight, length, and head circumference.

In attempting to comfort a newborn, many mother's offer

a nipple dipped in sugar water in order to soothe a baby after a painful procedure; hospital uses sugar water better known as "sweeties."

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hematocrit; The signs and symptoms of IVH include a sudden decrease in hematocrit, a severe and sudden unexplained deterioration of vital signs, bulging fontanels, changes in activity level, and sudden lethargy. The diagnosis is confirmed by cranial ultrasonography.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased; Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed; When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho D are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

The nurse working on a postpartum client must check lochia in terms of

amount, color, change with activity and time, and odor.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

applying ice; Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement.

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior?

attachment; Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth.

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

avoid products containing aspirin.

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools; NEC assessment includes assessing the newborn's health history and physical examination as well as laboratory and diagnostic testing. The onset of NEC is demonstrated by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock with RDS, temperature instability, lethargy, hypotension, and oliguria.

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication?

deep vein thrombosis; Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?

drop in estrogen and progesterone levels after birth; Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder.

When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn?

during the first 24 hours of life; Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. Physiologic jaundice is caused by the normal reduction of red blood cells and occurs in both breastfed and bottle-fed babies.

How frequently should the nurse perform the assessments during the first hour after birth?

every 15 minutes; Postpartum assessment is typically performed every 15 minutes for the first hour. After the second hour, assessment is performed every 30 minutes. The client has to be monitored closely during the first hour after delivery.

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?

face; Neonatal jaundice first becomes visible in the face and forehead. Identification is aided by pressure on the skin, since blanching reveals the underlying color. Jaundice then gradually becomes visible on the trunk and extremities.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?

generally 3 to 6 weeks; There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?

he nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients.

The parent reports that the health care provider said that the infant had a hernia but she can't remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated?

inguinal hernia; An inguinal hernia occurs primarily in males and allows the intestine to slip into the inguinal canal, resulting in swelling. If the intestine becomes trapped and circulation is impaired, surgery is indicated within a short period of time.

Acquaintance/attachment phase

is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.

Letting-go-phase

is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together.

Taking-hold-phase

is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task.

Taking-in-phase

is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs.

Reciprocity

is the process by which the infant's abilities and behaviors elicit parental responses (i.e., the smile by the infant gets a smile and kiss in return).

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?

massage the boggy fundus until its firm; The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.

Breast engorgement

may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the doctor needs to be called.

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

moderate; Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

Taking-in phase

occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience.

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

oxytocin; causes the uterus to contract to improve uterine tone and reduce bleeding.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

perform hand-washing before breast-feeding.

A 32 weeks' gestation newborn is admitted to the neonatal intensive care unit. The assessment reveals a pale dyspneic newborn with marked tremors, a bulging anterior fontanel, and a high-pitched cry. What diagnosis best correlates with the assessment findings?

periventricular-intraventricular hemorrhage; If periventricular-intraventricular hemorrhage is suspected, evaluate the newborn for a drop in hematocrit, pallor, and poor perfusion as evidenced by respiratory distress and oxygen desaturation. Note seizures, lethargy, or other changes in level of consciousness, bulging fontanel, weak sucking, metabolic acidosis, high-pitched cry, or hypotonia. Palpate the anterior fontanel for tenseness.

A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority?

preventing infection; A congenital condition of the newborn with a spinal deformity puts the newborn at risk for infection. A myelomeningocele is a fluid-filled sac on the spine that includes part of the spinal cord defect and the meninges. This cyst on the outside of the newborn requires surgical intervention. Although nutrition, GI function, and motor function are all important to the health of the newborn, the spinal and meninges defect puts the newborn at high risk for infection.

The nurse would identify which hormone that is responsible for milk production?

prolactin.

Which nursing action is required when caring for the post-term infant?

serial blood glucose levels.

The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort?

swaddle and decrease stimulation; Swaddling and decreasing stimulation is helpful in providing relaxation and comfort for the newborn withdrawing from alcohol. Benzodiazepines are to prevent seizure activity. Providing small amounts of formula frequently supports weight gain. Promoting parental bonding is important for the newborn and parents to help the infant meet developmental milestones.

Which sign appears early in a neonate with respiratory distress syndrome?

tachypnea more than 60 breaths per minute. Tachypnea and expiratory grunting occur early in respiratory distress syndrome to help improve oxygenation. Poor capillary filling time, a later manifestation, occurs if signs and symptoms aren't treated. Crackles occur as the respiratory distress progressively worsens. A pale gray skin color obscures earlier cyanosis as respiratory distress symptoms persist and worsen.

he nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition?

urinary tract infection

Taking-hold phase

usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy.

What is a significant cause of postpartum hemorrhage?

uterine atony

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

weak and rapid pulse; The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible.

A nurse is caring for a nonbreast-feeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?

wear a well-fitting bra; The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

When the fundus is boggy

you must assess whether or not the client has voided, assist in voiding and then massage the fundus to see if it hardens.