SAUNDERS MATERNITY: Postpartum, Intrapartum

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply. 1.Station 2.Dilation 3.Effacement 4.Bloody show 5.Contraction effort

1, 2, 3 Rationale:The vaginal examination for a client in labor specifically determines effacement 0% to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination. Test-Taking Strategy(ies):Focus on the subject, purpose of a vaginal exam for a client in labor. Specific knowledge of the vaginal exam and what the nurse will be checking when performing this assessment is vital to answer this question. Think about this exam and what it entails to answer correctly.

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply. 1. "I will be sure to wash my hands thoroughly and frequently." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "My baby needs to receive all of the recommended vaccines at the regular schedule." 4. "My baby has no symptoms so it is not likely that he has gotten the infection from me." 5. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

2, 4 Rationale:Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. Therefore, HIV-positive clients should be encouraged to bottle-feed their neonates. Currently, in the United States, HIV infection is considered a contraindication for breast-feeding. Note that this may not be the practice in other countries. In developing countries where HIV is prevalent, the benefits of breast-feeding for infants may outweigh the risk of contracting HIV from infected mothers. Frequent hand washing is encouraged. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for their first 6 weeks of life. The infant born to a mother with HIV may be asymptomatic for the first several years of life and should be monitored for immunodeficiency. Infants at risk need to receive all recommended vaccines at the regular schedule; however, no live vaccines should be administered. Test-Taking Strategy(ies):Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select the incorrect statements. Thinking about the modes of transmission of HIV and recalling that breast-feeding is discouraged in HIV-positive women will assist in answering correctly. Also, recalling that the infant born to a mother with HIV may be asymptomatic for the first several years of life will assist in answering.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

2. Assess the baseline fetal heart rate.

A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a −2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

3, 5 Rationale:Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary after this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part. Test-Taking Strategy(ies):Note the strategic words, most likely. Focus on the subject, an amniotomy. Recalling that amniotomy is performed to augment labor if the progress begins to slow will direct you to the correct option.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1.The contractions are regular. 2.The membranes have ruptured. 3.The cervix is dilated completely. 4.The client begins to expel clear vaginal fluid. 5.The spontaneous urge to push is initiated from perineal pressure.

3, 5 Rationale:The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1. Test-Taking Strategy(ies):Eliminate options 2 and 4 first because they are comparable or alike. From the remaining options, recalling that regular contractions occur before the second stage of labor will direct you to the correct option.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. The Ferguson reflex is initiated from perineal pressure.

3, 5 Rationale:The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1. Test-Taking Strategy(ies):Eliminate options 2 and 4 first because they are comparable or alike. From the remaining options, recalling that regular contractions occur before the second stage of labor will direct you to the correct option.

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? 1. "The medication will affect you and your pain level only when given during a contraction." 2. "The medication will provide optimal relief when it is given while your pain level is highest." 3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 4. "You will experience a lower incidence of adverse effects from the medication when administered during a contraction."

3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." Rationale:Intravenous medication should be administered slowly in small doses starting at the beginning of a contraction and carrying over for 3 to 5 contractions. This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus. Although this method of administration may decrease the amount of medication reaching the fetus, it does not totally eliminate effects of the medication on the fetus. The statements in the remaining options are incorrect information about the medication effects. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Eliminate option 1 because of the closed-ended word "only." Focus on the fact that the nurse is administering the medication during a contraction. In addition, think about what processes occur within the placenta and the uterus during a contraction that would also relate to circulation. This will direct you to the correct option.

The postpartum unit nurse has provided information on performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that it will promote which action? 1. Numb the tissue. 2. Stimulate a bowel movement. 3. Reduce the edema and swelling. 4. Assist in healing and provide comfort.

4. Assist in healing and provide comfort. Rationale:Warm, moist heat is used after the first 24 hours after tissue trauma from a vaginal birth to provide comfort, promote healing, and reduce the incidence of infection. This warm, moist heat is provided via a sitz bath. Ice is used in the first 24 hours to numb the tissue and reduce edema. Promoting a bowel movement is best achieved by ambulation. Test-Taking Strategy(ies):Focus on the subject, the purpose of a sitz bath. Visualize this procedure to direct you to the correct option. Also, use principles related to heat and cold to answer correctly.

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? 1. Assessing the mother's reflexes 2. Taking the mother's temperature 3. Taking the mother's apical pulse 4. Monitoring the mother's blood pressure

4. Monitoring the mother's blood pressure Rationale:A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia. Test-Taking Strategy(ies):Focus on the subject, parameters to monitor for the client with a lumbar epidural block. Use knowledge regarding the effects produced by regional anesthesia to answer this question. Recalling that this type of anesthesia causes hypotension will direct you to the correct option.

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? 1. Ambulating 2. Breast-feeding 3. Taking sitz baths 4. Increasing activity after arriving home

2. Breast-feeding Rationale:Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. Ambulating, taking sitz baths, and increasing activity do not affect afterpains. Test-Taking Strategy(ies):Note the subject, afterpains and their occurrence. Eliminate ambulating and increasing activity because they are comparable or alike. From the remaining choices, recall the action of oxytocin and that oxytocin is released during breast-feeding to assist you in answering correctly.

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How should the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used.ates improper positioning. Cracked nipples, breast engorgement, and sore nipples are all complications that are the result of improper positioning. 1.An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR). 2.A 12-hour post-cesarean section delivery gravida 3, para 3 who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 3.A 48-hour post-cesarean section delivery gravida 1, para 1 who reports not yet having a bowel movement since delivery and requests a stool softener. 4.A 24-hour post-vaginal delivery gravida 4, para 4 who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen.

2, 4, 1, 3 Rationale:The 12-hour post-cesarean section delivery client should be assessed first because she is reporting a sensation of wetness; this could be excessive bleeding. The 24-hour post-vaginal delivery client is complaining of pain, which can be treated easily with oral medications; therefore, this client should be assessed next. The 8-hour post-vaginal delivery client who is scheduled for a bilateral tubal ligation has an IV infusion. A baseline assessment must be conducted preoperatively for a bilateral tubal ligation; however, the scheduled operative time is 5 hours away. The client who had a cesarean section delivery 48 hours ago is assessed last, as she is the farthest out from delivery and the effectiveness of a stool softener will be achieved over time with continued administration. Test-Taking Strategy(ies):Use the ABCs-airway, breathing, and circulation-to determine the priority client. The 12-hour post-cesarean section delivery client could be bleeding and warrants careful and immediate assessment. Before having sensation in the lower extremities, there is little movement, which can promote stasis of blood, clotting, and increased bleeding. When bleeding does occur, it frequently absorbs into the underpad beneath the buttocks. The 24-hour post-vaginal delivery client is a gravida 4; multiparas are going to experience more intense abdominal cramping after delivery and nursing and need medication to alleviate this discomfort. A baseline assessment must be conducted preoperatively for a bilateral tubal ligation; however, the scheduled operative time is 5 hours away. There is no information indicative of this client needing priority assessment over the other clients. The 48-hour post-cesarean section delivery client is complaining of not yet having a bowel movement; this is not the priority. This is treated with regular use of a stool softener, increasing fluid intake, and fiber-rich foods.

The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? 1. "It is the application of pressure to the sacrum to relieve a backache." 2. "It is a form of biofeedback to enhance bearing-down efforts during delivery." 3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." 4. "It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest."

3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." Rationale:Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage also provides tactile stimulation to the fetus. Options 1, 2, and 4 are inaccurate descriptions of effleurage. Test-Taking Strategy(ies):Note the subject, effleurage. Eliminate option 1 because not all clients in labor experience backache. Focus on the words in early labor to eliminate option 2. Eliminate option 4 because it focuses on stimulation of uterine activity rather than relaxation.

A woman infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates an understanding of the instructions? Select all that apply. 1. "I am going to need to bottle-feed my baby." 2. "I need to wash my hands before and after bathroom use." 3. "I can transmit the infection to my baby when I breast-feed." 4. "My baby won't need any medication to prevent the virus because my baby appears normal." 5. "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."

1, 2, 3, 5 Rationale:Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding; therefore, HIV-positive clients should be encouraged to bottle-feed their neonates. Note that in the United States HIV infection is considered a contraindication for breast-feeding. However, this may not be the practice in other countries. In developing countries where HIV is prevalent, the benefits of breast-feeding for infants outweigh the risk of contracting HIV from infected mothers. Frequent hand washing is encouraged. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life. Support groups and community agencies can be identified to assist the parents with the newborn's home care, the impact of the diagnosis of HIV infection, and available financial resources. Test-Taking Strategy(ies):Focus on the subject, instructions for a woman infected with the human immunodeficiency virus (HIV) who has given birth to an infant. Specific knowledge regarding the transmission of HIV from mother to neonate and knowledge of infection control measures will assist in answering correctly.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 4."I will start my estrogen birth control pills again as soon as I get home." 5."I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1, 2, 3, 6 Rationale:The postpartum client should wear a bra that is well fitted and supportive. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or medications. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Test-Taking Strategy(ies):Focus on the subject and note the words understood the instructions. Think about the physiology associated with milk production and the complications of breast-feeding to answer correctly.

The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should report which abnormal findings to the primary health care provider (PHCP)? Select all that apply. 1.Clear, dark amber amniotic fluid 2.Amniotic fluid volume of 800 mL 3.Light green amniotic fluid with no odor 4.Thick white amniotic fluid with no odor 5.Straw-colored amniotic fluid with flecks of vernix

1, 3, 4 Rationale:Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin, watery consistency and may have a mild odor. The normal amount of amniotic fluid ranges from 500 to 1000 mL. Dark amber color, light green color, and thick white color are not descriptions of normal amniotic fluid and should be brought to the PHCP's attention. Test-Taking Strategy(ies):Focus on the subject, the normal characteristics of amniotic fluid. Specific knowledge of the characteristics of normal amniotic fluid and the normal amount is required to answer this question. Remember that the amniotic fluid is straw-colored with flecks of vernix caseosa to choose the correct options easily.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum

1. 3 days postpartum Rationale:After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect. Test-Taking Strategy(ies):Focus on the subject and use general principles related to postpartum care. Eliminate options 2 and 4 first because of the length of time stated in these options. From the remaining options, eliminate option 3, because it would seem unreasonable that bowel function would return that quickly in the postpartum woman.

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action? 1. Determine the fetal heart rate. 2. Provide peripads for the client. 3. Take the client's blood pressure. 4. Note the amount, color, and odor of the amniotic fluid.

1. Determine the fetal heart rate. Rationale:When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Taking the blood pressure and noting the characteristics of the amniotic fluid are also appropriate actions but are not the initial actions in this situation. The nurse may assist the client in cleaning, changing clothing, and providing peripads, but determining the fetal heart rate is the initial action. Test-Taking Strategy(ies):Note the strategic word, initial. Use principles of prioritizing when answering this question and the ABCs-airway, breathing, and circulation. Fetal heart rate is associated with fetal breathing and circulation.

The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the primary health care provider's prescriptions and should expect to note which prescribed treatment for this condition? 1. Oxytocin infusion 2. Increased hydration 3. Administration of a tocolytic medication 4. Administration of a medication that will provide sedation

1. Oxytocin infusion Rationale:Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. The remaining options identify therapeutic measures for a client with hypertonic dysfunction. Test-Taking Strategy(ies):Note the subject, hypotonic uterine dysfunction. Identify the option that will help to stimulate labor. This should direct you to option 1.

A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The primary health care provider has prescribed an epidural block. Which nursing intervention should be implemented after the epidural block has been placed? 1. Palpate the bladder at frequent intervals. 2. Encourage the woman to walk to progress the labor. 3. Assess the blood pressure frequently for hypertension. 4. Encourage the woman to assume a supine position after the epidural has been placed.

1. Palpate the bladder at frequent intervals Rationale:The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The woman loses the sensation that she needs to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Ambulation is not allowed because of the anesthesia. The woman is encouraged to lie on her side to increase placental perfusion to the fetus. Hypotension, not hypertension, is a concern. Test-Taking Strategy(ies):Focus on the subject, nursing care following an epidural block. Once an epidural block is placed, the client will not be allowed to walk because there is anesthesia from the lumbar area to the sacral area. This is a safety precaution for the woman and her fetus. This eliminates option 2. Option 3 can be eliminated because a side effect of an epidural block is hypotension, not hypertension. Once an epidural block is placed, the woman is encouraged to lie on her left side to increase placental perfusion to the fetus. This leaves option 1, palpating the bladder, as the only correct choice.

On March 10, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7 the previous year. The nurse plans care based on which interpretation? 1. The client is possibly in preterm labor. 2. The fetus may not be viable at delivery. 3. The client may require labor augmentation. 4. The fetus is at high risk for shoulder dystocia.

1. The client is possibly in preterm labor. Rationale:According to Naegele's rule, by subtracting 3 months and adding 7 days and 1 year to this client's LMP the nurse can determine that her estimated date of delivery (EDD) is April 14. This client is in the labor and delivery unit to be evaluated for the presence of labor more than 1 month before her EDD; therefore, she is possibly in preterm labor. Viability is said to occur between the 22nd and 25th weeks of gestation. This fetus is approximately 4 weeks before term. If this client truly is in labor, the primary health care provider's plan would be to try to stop the labor in order to prevent delivery at this early stage in the pregnancy. This would eliminate option 3, labor augmentation. Because of the typical 36-week gestational size of a fetus, 2200 to 2900 g, there would be no risk for a difficult shoulder delivery. Test-Taking Strategy(ies):Note the subject, the initial nursing assessment for a client potentially in labor. Use knowledge of Naegele's rule for this question. Once you have determined the client's EDD, you can determine that the day she is being seen on the unit is more than a month before the EDD and eliminate the options that do not apply.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1. The diet should include additional fluids. Rationale:The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed. Test-Taking Strategy(ies):Note the subject, teaching for the breast-feeding client. Remember that fluids and calories should be increased when the client is breast-feeding.

Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor? 1."I feel like I need to push." 2."My contractions seem to be getting stronger." 3."I am glad that I have several minutes to rest between contractions." 4."Warm fluid is running down my legs each time I have a contraction."

1."I feel like I need to push." Rationale:The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. At this time, the laboring woman typically experiences the desire to push. Contractions becoming stronger are experienced throughout labor and do not indicate that she has reached stage 2. Having several minutes to rest between contractions does not describe the end of transition. Leaking of amniotic fluid does not mean that she is completely dilated. Test-Taking Strategy(ies):Note the strategic words, most likely. Focus on the subject, specific knowledge of the stages of labor, to assist you in answering the question. Eliminate contractions becoming stronger, leakage of amniotic fluid, and several-minute recuperation time as nonspecific to the second stage of labor.

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and also notes that this is the client's first child. Which nursing interventions are most appropriate in assisting the promotion of mother-infant interaction and bonding? Select all that apply. 1.Accepting the client's feelings 2.Acknowledging the client's apprehension 3.Assisting the client with giving the baths to allow her to become more at ease 4.Leaving the infant with the client so that she will be required to provide the care 5.Taking the newborn back to the nursery to provide rest periods for the new mother

1.Accepting the client's feelings 2.Acknowledging the client's apprehension 3.Assisting the client with giving the baths to allow her to become more at ease Rationale:Acceptance of the new mother's feelings and acknowledgment of her apprehension can help an unsure mother begin to participate in caring for her newborn. Assistance will help the client become more at ease. A client with no experience of handling infants may be fearful and reluctant to handle her newborn or to take on physical care on her own. Leaving the infant with the mother so that she will be required to provide the care will produce additional apprehension. Removing the infant to the nursery does not promote mother-infant bonding. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Read each option carefully, noting that addressing the client's feelings, apprehension, and skills will assist this client with mother-infant bonding.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1.Provide pain relief measures. 2.Prepare the client for an amniotomy. 3.Promote ambulation every 30 minutes. 4.Monitor the oxytocin infusion closely.

1.Provide pain relief measures. Rationale:Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest. Test-Taking Strategy(ies):Focus on the strategic word, priority. Also note that options 2, 3, and 4 are comparable or alike and are therapeutic measures for hypotonic dysfunction.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1.Supine position with a wedge under the right hip 2.Trendelenburg's position with the legs in stirrups 3.Prone position with the legs separated and elevated 4.Semi-Fowler's position with a pillow under the knees

1.Supine position with a wedge under the right hip Rationale:Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-Fowler's position is not practical for this type of abdominal surgery. Test-Taking Strategy(ies):Focus on the subject, positioning the pregnant woman. Visualizing each of the positions identified in the options and considering the effect that the position may have on the mother and the fetus will direct you to the correct option.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1. Contact the obstetrician. 2. Continue to monitor the client. 3. Report the FHR to the anesthesiologist. 4. Prepare for imminent delivery of the fetus.

2. Continue to monitor the client. Rationale:The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications. Test-Taking Strategy(ies):Eliminate options 1 and 3 first because they are comparable or alike. Regarding the remaining choices, recalling the expected findings during labor will direct you to the correct option.

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate? 1. Massage the fundus. 2. Cover the client with a warm blanket. 3. Place the client in Trendelenburg's position. 4. Contact the primary health care provider (PHCP).

2. Cover the client with a warm blanket Rationale:In the postpartum period, a woman may experience a shaking, uncontrollable chill immediately after birth. The exact cause of this fairly common event is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The appropriate nursing action is to provide a warm blanket to the client and a warm drink if oral intake is not contraindicated. Test-Taking Strategy(ies):Use knowledge of the immediate postpartum period. Focusing on the subject, normal physiological occurrences in the postpartum period, will direct you to the correct option, to provide warmth.

The postpartum unit nurse is creating a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan? 1. Use a low-pitched voice to speak to the infant. 2. Encourage the mother to hold the infant when the infant cries. 3. Encourage the parents to allow the infant to sleep in the parental bed. 4. Encourage the mother to allow the nursing staff to care for the infant during her hospital stay until she is discharged.

2. Encourage the mother to hold the infant when the infant cries. Rationale:Holding the infant close and allowing the infant to feel the mother's warmth will initiate a positive experience for the mother and will console the infant. The use of a high-pitched voice and participating in infant care are additional methods of promoting parent-infant attachment. Infants should not be allowed to sleep in the parental bed. The parents require time alone as a couple. In addition, the danger of suffocation of the infant exists if the infant is allowed to sleep between parents. Test-Taking Strategy(ies):Focus on the subject, promoting parent-infant bonding. Note the relationship between the subject and the correct option, which uses the word hold.

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? 1. Hourly 2. Every 15 minutes 3. Every 30 minutes 4. Before each contraction

2. Every 15 minutes Rationale:The second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor. Test-Taking Strategy(ies):Focus on the subject, that the client is dilated 10 cm. Noting the words at least will assist in directing you to the option that identifies the most frequent time frame.

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? 1. Stimulate the labor process. 2. Prevent dehydration and hypoxemia. 3. Avoid the necessity of a cesarean section. 4. Eliminate the need for analgesic administration.

2. Prevent dehydration and hypoxemia. Rationale:A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the necessity of a cesarean section, or eliminate the need for analgesic administration. Test-Taking Strategy(ies):Focus on the subject, sickle cell disease. Note the relationship between adequate intravenous fluid intake and oxygen consumption in the question and prevent dehydration and hypoxemia in the correct option. This relationship and knowledge regarding the care measures for sickle cell anemia will direct you easily to the correct option.

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1.Ask the client to turn on her side. 2.Ask the client to urinate and empty her bladder. 3.Massage the fundus gently before determining the level of the fundus. 4.Ask the client to lie flat on her back, with her knees and legs flat and straight.

2.Ask the client to urinate and empty her bladder. Rationale:Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When performing fundal assessment, the woman is asked to lie flat on her back, with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm. Test-Taking Strategy(ies):Note the strategic word, initial. Attempt to visualize the procedure when answering the question. This should easily direct you to the correct option.

A postpartum unit nurse is caring for a stable client 12 hours after delivering a healthy newborn. At this time in the postpartum period, what is the recommended frequency for the nurse to assess the client's vital signs? 1.Every hour 2.Every 4 hours 3.Every 24 hours 4.Every 30 minutes

2.Every 4 hours Rationale:During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay. Test-Taking Strategy(ies):Focus on the subject, postpartum assessment for a stable client 12 hours postpartum. Read each option carefully. Noting the word stable in the question will assist in answering correctly.

Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother? 1.Apple and orange 2.Peanut butter and jelly sandwich and glass of 2% milk 3.Hamburger with bun, French fries, and glass of skim milk 4.4-ounce (113 gm) grilled chicken breast, sweet potato, and 16-ounce milkshake

2.Peanut butter and jelly sandwich and glass of 2% milk Rationale:If the client is breast-feeding, her calorie needs increase by approximately 500 calories/day. Adding only an apple and an orange will be too few calories. The hamburger meal and the chicken breast meal contain significant calories over the required 500 calories. Test-Taking Strategy(ies):Focus on the subject, calorie needs for a breast-feeding mother. Knowledge of nutritional needs is needed to answer correctly. Remember that calorie needs in the breast-feeding client increase by 500 calories/day.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1.Ambulation 2.Rest between contractions 3.Change positions frequently 4.Consume oral food and fluids

2.Rest between contractions Rationale:The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time. Test-Taking Strategy(ies):Note the strategic word, primary. Also, noting the words pushing effectively will assist in directing you to the correct option.

The nurse is preparing to care for a client in labor. The primary health care provider (PHCP) has prescribed an intravenous (IV) infusion of oxytocin. The nurse should ensure that which is implemented before the beginning of the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside

3. Continuous electronic fetal monitoring Rationale:Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question that indicate the need for antibiotics or complete bed rest. It is not necessary to place a code cart at the bedside of a client receiving an oxytocin infusion. Test-Taking Strategy(ies):Use the ABCs-airway, breathing, and circulation-to assist in answering the question. Option 3 is the only one that addresses oxygenation and circulation.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client? 1. Apply a heating pad to breasts for comfort. 2. Wear a breast shield to correct nipple inversion. 3. Wear a supportive brassiere continuously for 72 hours. 4. Use the manual breast pump provided to express milk.

3. Wear a supportive brassiere continuously for 72 hours. Rationale:Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant sucking) or increase in circulation (heating pad) will increase milk production or cause the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be necessary if the mother chooses not to breast-feed her infant. Test-Taking Strategy(ies):Focus on the subject, client instructions about formula-feeding. Knowledge of the lactation process will allow you to eliminate applying a heating pad and manually pumping the breasts because these actions are breast stimulants. The correction of nipple inversion is not necess

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day? 1.100 2.300 3.500 4.1000

3. 500 Rationale:If the client is breast-feeding, her calorie needs increase by approximately 500 calories/day. The client should also be instructed on the need for increased fluids and the need for prenatal vitamins and iron supplements. Test-Taking Strategy(ies):Focus on the subject, calorie needs for a breast-feeding mother. Knowledge of nutritional needs is needed to answer correctly. Remember that calorie needs in the breast-feeding client increase by 500 calories/day.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1.Fentanyl 2.Morphine sulfate 3.Butorphanol tartrate 4.Meperidine hydrochloride

3.Butorphanol tartrate Rationale:Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients. Test-Taking Strategy(ies):Focus on the subject, the analgesic contraindicated for a client who has a history of opioid dependency. Use knowledge of the medications in the options; it is necessary to remember that butorphanol tartrate can precipitate withdrawal symptoms in an opioid-dependent client.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1.Raise the head of the client's bed. 2.Obtain hemoglobin and hematocrit levels. 3.Instruct the client to request help when getting out of bed. 4.Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.

3.Instruct the client to request help when getting out of bed. Rationale:Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a prescription. Option 4 is unnecessary. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Focus on the subject, client safety. Option 4 is unnecessary and should be eliminated first. Elevating the client's head is not a helpful intervention. To select from the remaining options, recall that safety is a primary issue.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? 1.Noting whether the heart rate is greater than 140 beats/minute 2.Placing the diaphragm of the Doppler on the mother's abdomen 3.Palpating the maternal radial pulse while listening to the FHR 4.Performing Leopold's maneuvers first to determine the location of the fetal heart

3.Palpating the maternal radial pulse while listening to the FHR Rationale:The nurse should simultaneously palpate the maternal radial or carotid pulse and auscultate the FHR to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 beats/minute or placing the diaphragm of the Doppler on the mother's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuvers may help the examiner to locate the position of the fetus but will not ensure a distinction between the 2 heart rates. Test-Taking Strategy(ies):Focus on the subject, determining the FHR. The correct option is the only choice that identifies an action that will directly distinguish the maternal heart rate from the FHR.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression? 1.The mother is caring for the infant in a loving manner. 2.The mother demonstrates an interest in the surroundings. 3.The mother constantly complains of tiredness and fatigue. 4.The mother looks forward to visits from the father of the newborn.

3.The mother constantly complains of tiredness and fatigue. Rationale:Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty concentrating are also present. The mother would have little interest in food and would experience sleep disturbances. Test-Taking Strategy(ies):Focus on the subject, postpartum depression. Note the strategic words, need for follow-up. These words indicate a negative event query and the need to select the option that indicates potential depression. Note that options that contain positive maternal behaviors (caring in a loving manner, interest in surroundings, looking forward to visits from the father) would not indicate postpartum depression.

The nursing instructor is reviewing the plan of care for a postpartum client with a student. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which responses made by the student indicate an understanding of this phase? Select all that apply. 1. "The client would be independent." 2. "The client initiates activities on her own." 3. "The client participates in mothering tasks." 4. "The client may complain of lack of sleep and fatigue." 5. "The client is self-focused and talks to others about labor."

4, 5 Rationale:Rubin has identified 3 phases of regeneration during the postpartum period. The taking-in phase occurs in the first 3 days postpartum, and the taking-hold phase occurs between days 3 and 10. During the taking-in phase, the new mother is attempting to integrate her labor and birth experience. She tends to need sleep and feels fatigued, talks about labor, and is self-focused and dependent. In the taking-hold phase, the client is more active and independent, initiates activities, and partakes in mothering tasks. In the letting-go phase, the mother may grieve over the separation of the baby from part of her body. Test-Taking Strategy(ies):Knowledge of Rubin's stages of regeneration during puerperium and the characteristics that occur in each of the phases is required to answer the question. Note the subject, the taking-in phase of Rubin's phases of regeneration. Read each option carefully and note the relationship of the description for this phase to the correct options.

Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. 1. Prepare for delivery. 2. Administer a tocolytic. 3. Administer an opioid antagonist. 4. Turn the woman to a lateral position. 5. Increase the rate of the intravenous infusion. 6. Administer oxygen by face mask at 10 L/minute.

4, 5, 6 Rationale:Maternal hypotension results in decreased placental perfusion, so the focus of nursing care should be to initiate interventions that increase oxygen perfusion to the fetus. Turning the woman to left lateral position assists in deflecting the uterus off of the vena cava, thus improving maternal circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the maternal blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the maternal circulation and increase oxygen delivery to the fetus. The woman is not revealing any signs or symptoms of imminent delivery, as she just received an epidural which is typically administered at 6 cm or earlier dilation, so option 1 can be eliminated. Administering a tocolytic can be eliminated because the decrease in placental perfusion is the result of maternal hypotension, not uterine hyperstimulation. Administering an opioid antagonist can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration. Test-Taking Strategy(ies):Note the strategic word, immediate. Focus on the subject, maternal hypotension resulting in poor placental perfusion. Determine which actions improve the maternal blood pressure and promote increased placental perfusion. This thinking will direct you to the correct options.

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? 1. "If I experience any sweating during the night, I should call the primary health care provider." 2. "If I have uterine cramping while breast-feeding, I should contact the primary health care provider." 3. "If I'm still having vaginal drainage in a week, I should contact the primary health care provider." 4. "If I notice any pain, redness, or swelling in my breasts, I should contact the primary health care provider."

4. "If I notice any pain, redness, or swelling in my breasts, I should contact the primary health care provider." Rationale:Signs and symptoms of infection include pain, redness, heat, and swelling of a localized area of the breast. If these signs or symptoms occur, the client needs to contact the primary health care provider. Sweating, experiencing uterine pains with breast-feeding, and lochia after 7 days are normal changes that occur in the postpartum period. Test-Taking Strategy(ies):Focus on the subject, breast-feeding in the postpartum period. Note the words indicates an understanding. Note the words pain, redness, or swelling in the correct option. All of these are signs of infection.

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes, and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1. Exhaustion 2. Valsalva maneuver 3. Involuntary grunting 4. Fear of losing control

4. Fear of losing control Rationale:Pain, helplessness, panicking, and fear of losing control are possible behaviors in the transition phase of the first stage of labor. Options 1, 2, and 3 are not indicative of the description provided in the question. Test-Taking Strategy(ies):Note the strategic word, best. Focus on the data in the question. Recall that during the transition phase of labor women may feel out of control. This will direct you to the correct option.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? 1. Light green, with no odor 2. Clear and dark amber in color 3. Thick and white, with no odor 4. Pale straw in color, with flecks of vernix

4. Pale straw in color, with flecks of vernix Rationale:Amniotic fluid normally is pale straw in color and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid should not be thick and white; this could be an indication of infection. Test-Taking Strategy(ies):Focus on the subject, normal amniotic fluid. Recall that the amniotic fluid normally is pale and straw-colored and may contain flecks of vernix caseosa.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the primary health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. Rationale:Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Options 1, 2, and 3 are comparable or alike in that they indicate the need for further intervention. Also, knowing that accelerations indicate fetal well-being will direct you to the correct option.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1."I won't be in labor until my baby drops." 2."My contractions will be felt in my abdominal area." 3."My contractions will not be as painful if I walk around." 4."My contractions will increase in duration and intensity."

4."My contractions will increase in duration and intensity." Rationale:True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor. Test-Taking Strategy(ies):Focus on the subject, the signs of true labor. Noting the word true in the question and its relationship to the words increase in duration and intensity in the correct option will direct you to this option.

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often should the nurse plan to take the client's vital signs? 1.Hourly for the first 2 hours and then every 4 hours 2.30 minutes during the first hour and then every hour for the next 2 hours 3.5 minutes for the first 30 minutes and then every hour for the next 4 hours 4.15 minutes during the first hour and then every 30 minutes for the next 2 hours

4.15 minutes during the first hour and then every 30 minutes for the next 2 hours Rationale:During the immediate postpartum period, vital signs are taken every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. Vital signs are monitored thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay. Test-Taking Strategy(ies):Focus on the subject, immediate postpartum care. Note that the nurse is caring for the client in the immediate postpartum period. Read each option carefully. It is not necessary to take vital signs every 5 minutes unless an alteration in physiological integrity has occurred during the labor period; therefore, eliminate option 3. Eliminate options 1 and 2 next because the time frames are not frequent enough in the immediate postpartum period.

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen. The nurse documents these observations as signs of which condition? 1.Hematoma 2.Uterine atony 3.Placenta previa 4.Placental separation

4.Placental separation Rationale:As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations. Test-Taking Strategy(ies):Focus on the subject, the umbilical cord lengthening. Hematoma, uterine atony, and placenta previa are comparable or alike in that they identify complications of pregnancy. Placental separation indicates a normal finding following vaginal delivery of the newborn infant.

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes a spurt of blood from the vagina. The nurse should document this observation as signs of which condition? 1.Hematoma 2.Uterine atony 3.Placenta previa 4.Placental separation

4.Placental separation Rationale:As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other options are not characterized by these findings. Test-Taking Strategy(ies):Focus on the data in the question, a spurt of blood from the vagina. Options 1, 2, and 3 are comparable or alike in that they identify complications of pregnancy and labor and delivery. Placental separation indicates a normal finding following vaginal delivery of the newborn and is the correct choice.

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant? 1.Massage the breasts, applying gentle pressure on the areolas with the thumb and forefinger. 2.Have the mother grasp her areola between the thumb and forefinger and tug firmly to get the nipple to protrude. 3.Encourage the mother to take a cool shower, allowing the water to run over the breasts, because this will encourage the nipples to protrude. 4.Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

4.Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp HomeHelpCalculator Study Mode Question 14 of 34 ID: 4332 | Maternity_Postpartum_final.htm #4436 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant? Rationale:Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn infant to grasp the nipple. Massaging the breast is an appropriate instruction for the mother with engorgement but will not help with resolving inverted nipples. True inverted nipples will retract if the areola is pressed between the thumb and forefinger. Having the client take a cool shower will only make the mother cold, and it has no effect on inverted nipples. Test-Taking Strategy(ies):Focus on the subject, measures to promote breast-feeding. Focus on the words inverted nipples and read each option carefully to assist in directing you to the correct option.

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant? 1.The mother has cracked nipples and feeds the infant with a supplemental bottle. 2.The mother complains of breast engorgement, and the infant demonstrates difficulty in latching onto the breast. 3.The mother is breast-feeding the infant with the infant's head turned toward her breast and the body flat in her arms; the mother has sore nipples, and the infant has a suck blister. 4.The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

4.The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow. Rationale:The infant should be positioned completely facing the mother with head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. The infant's head turned toward the breast and the body flat in the mother's arms is incorrect because it demonstrates improper positioning. Cracked nipples, breast engorgement, and sore nipples are all complications that are the result of improper positioning. Rationale:The infant should be positioned completely facing the mother with head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. The infant's head turned toward the breast and the body flat in the mother's arms is incorrect because it demonstrates improper positioning. Cracked nipples, breast engorgement, and sore nipples are all complications that are the result of improper positioning.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1.The mother is observed talking to the newborn. 2.The mother performs cord care for the newborn. 3.The mother verbalizes discomfort with the new role of motherhood. 4.The mother requests that the nurse feed the newborn because she is feeling fatigued.

4.The mother requests that the nurse feed the newborn because she is feeling fatigued. Rationale:The nurse should be alert to maladaptive interaction in the maternal-infant bonding processes. If the nurse notes that the mother is avoiding interaction with the newborn or is avoiding caring for the newborn, the nurse should suspect the potential for a maladaptive interaction. Talking to the newborn or willingness to perform cord care does not indicate a maladaptive response. Expressing discomfort with the new role of motherhood is a normal, expected process, and it is important for the mother to verbalize concerns. Test-Taking Strategy(ies):Focus on the subject, a maladaptive behavior. The only option that indicates this potential is the correct one.