Unit 3 Exam (premature baby)

Which medication would the nurse identify as aiding in uterine evacuation in cases of miscarriage? Oxytocin Misoprostol Dinoprostone Methylergonovine

Dinoprostone Dinoprostone is a prostaglandin E 2 abortifacient that causes uterine evacuation in cases of miscarriage. Oxytocin induces labor by enhancing uterine contractions and promotes milk ejection during lactation. Misoprostol is a stomach protectant that helps in cervical ripening. Methylergonovine is an oxytocic ergot alkaloid used to treat postpartum uterine atony and hemorrhage.

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: the frequency and duration of contractions are measured in seconds for consistency. the examiner's hand should be placed over the fundus before, during, and after contractions. contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. the resting tone between contractions is described as either placid or turbulent.

the examiner's hand should be placed over the fundus before, during, and after contractions. The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.

A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits: a sleepy, sedated affect. a respiratory rate of 10 breaths/min. deep tendon reflexes of 2+. absent ankle clonus.

a respiratory rate of 10 breaths/min. Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Deep tendon reflexes of 2+ are a normal finding. Absent ankle clonus is a normal finding.

A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to: assess the fetal heart rate (FHR) pattern. perform a vaginal examination. inspect the characteristics of the fluid. assess maternal temperature.

assess the fetal heart rate (FHR) pattern. The first nursing action after the membranes are ruptured is to check fetal heart rate (FHR). Compression of the cord could occur after rupture leading to fetal hypoxia as reflected in an alteration in FHR pattern, characteristically variable decelerations. The same initial action should follow artificial rupture of the membranes (amniotomy). These are all important and should be done after the FHR and pattern are assessed.

A client with hypertension has labor pains before the 35th week of gestation. Which pharmacological intervention would the nurse anticipate to be beneficial for this client? Administer terbutaline. Administer magnesium sulfate. Prepare the client for an abortion. Administer sedatives and maintain hydration.

Administer magnesium sulfate. Magnesium sulfate is the medication of choice for maintaining pregnancy in preterm labor in hypertensive clients. Terbutaline is used to maintain pregnancy in preterm labor by relaxing the uterine smooth muscle. An abortion is advisable if the preterm labor starts before the 20th week of gestation because the fetus may be nonviable. The use of sedatives and body hydration measures are nonpharmacological interventions to maintain pregnancy in preterm labor.

A pregnant woman is experiencing morning sickness and breast tenderness. In the ninth week after her last menstrual period, she is rushed to the hospital with severe left shoulder pain, blood pressure of 90/60 mm Hg, and heart rate of 112 beats/min. What is the best diagnostic test that is expected to be ordered? Serum hemoglobin Transvaginal ultrasound 12-lead electrocardiogram (ECG) Serial β-human chorionic gonadotropin levels

Transvaginal ultrasound Because the patient is known to be pregnant, a transvaginal ultrasound will be used to assess for ectopic pregnancy and tubal rupture. Serum hemoglobin and 12-lead ECG would not define a diagnosis related to the manifestations that she has. Serial β-human chorionic gonadotropin levels could be used if the patient was stable to determine if a spontaneous abortion is occurring because the levels would decrease over time.

Which criterion would the nurse use when assessing the gestational age of a preterm infant? Reflex stability Simian creases Breast bud size Fingernail length

Breast Bud size The size of the breast buds is an indication of gestational age. Small, underdeveloped nipples reflect prematurity. Reflex stability is not a reliable indicator of gestational age; also, reflexes may be impaired in full-term infants. The simian crease is a single palm crease that is a clinical manifestation of Down syndrome, not of prematurity. Although the nails may be longer in a postterm infant, nail length is not a reliable indicator in a preterm infant.

A pregnant client has labor pains; however, upon assessment, the nurse finds that the cervix is not dilated. Which medication would the nurse identify that could be used to promote labor? Oxytocin Nifedipine Dinoprostone Methylergonovine

Dinoprostone Dinoprostone induces cervical ripening. This action helps in the induction of labor at term. Oxytocin enhances labor when uterine contractions are weak and ineffective. Nifedipine is a calcium channel blocker used to maintain pregnancy during preterm labor. Methylergonovine reduces postpartum hemorrhage.

Which test is performed to determine if membranes are ruptured? Urine analysis Fern test Leopold maneuvers Artificial Rupture of Membranes (AROM)

Fern test A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. Artificial rupture of membranes (AROM) is the procedure of artificially rupturing membranes, usually with a device known as an AmniHook.

A female client is undergoing treatment for infertility. Therapy with clomiphene has been unsuccessful. The nurse anticipates that which treatment will be prescribed next? Estrogen Progesterone Human growth hormone Human chorionic gonadotropin

Human chorionic gonadotropin Clomiphene is used to induce pregnancy by triggering ovulation. If the desired result is not obtained, the second alternative is to administer human chorionic gonadotropin and gonadotropin-releasing hormone to stimulate ovulation. A combination of estrogen and progesterone is generally administered to treat female clients who have a gonadotropin deficiency. Human growth hormone injections are administered to treat adults with growth hormone deficiency.

Which statement by a new mother observing her preterm infant in the neonatal intensive care nursery indicates that she has not yet begun the bonding process? "It's such a tiny baby." "Do you think he'll make it?" "Why does he need to be in an incubator?" "My baby looks so much like my husband."

It's such a tiny baby By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word "he" denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.

A woman with endometriosis is seeking a cure. After identifying childbearing is no longer desired, the nurse should introduce which potential treatment? Danazol Leuprolide (Lupron) Nonsteroidal antiinflammatory drugs Surgical removal of endometrial implants

Surgical removal of endometrial implants The only cure for endometriosis is the surgical removal of all endometrial implants, which may include the uterus, fallopian tubes, and ovaries. Leuprolide is a gonadotropin-releasing hormone agonist that causes amenorrhea with menopausal side effects. Danazol is a synthetic androgen that inhibits the anterior pituitary. Nonsteroidal antiinflammatory drugs relieve pain but do not affect the problem of endometriosis.

When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to: maternal hyperthyroidism. initiation of epidural anesthesia that resulted in maternal hypotension. maternal infection accompanied by fever. alteration in maternal position from semirecumbent to lateral.

initiation of epidural anesthesia that resulted in maternal hypotension. Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position enhances placental perfusion and should result in a reassuring fetal heart rate (FHR) pattern.

Which question is most important to ask a client who arrives in the birthing unit with birth imminent? "Is this your first baby?" "Have your membranes ruptured?" "When did your contractions begin?" "When is your baby's expected date of birth?"

"When is your baby's expected date of birth?" It is most important to know whether this is a preterm or full-term pregnancy so appropriate preparations may be made for the neonate, so the first question is about the baby's expected date of birth. Asking whether this is the client's first baby is irrelevant at this time. Although the client may be asked whether her membranes have ruptured, it is not the priority when a birth is imminent, and prematurity must be known to enable appropriate preparations. The birth is imminent, so asking when her contractions began is also irrelevant at this time.

A female patient is recovering from rectocele repair surgery. Which interventions should be included in the plan of care? (Select all that apply.) Maintain complete bed rest. Administer a stool softener. Provide a cleansing enema. Apply ice to the perineal area. Urinary catheter care twice a day. Sitz bath may be used in a few days.

Administer a stool softener. Apply ice to the perineal area. Urinary catheter care twice a day. Administering a stool softener will reduce straining and disruption of the surgical repair. Ice will reduce pain and swelling at the surgical site. Urinary catheter care is provided twice a day to reduce catheter-associated urinary tract infections. A sitz bath may be given a few days after surgery for comfort. Maintaining strict bed rest is not indicated. A cleansing enema is provided before surgery, not after.

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? Administration of blood Preparation of the woman for invasive hemodynamic monitoring Restriction of intravascular fluids Administration of steroids

Administration of blood Primary medical management in all cases of disseminated intravascular coagulation (DIC) involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a woman with DIC because this can contribute to more areas of bleeding. Management of DIC includes volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

The nurse is teaching health promotion to a variety of women in a community center. How should the nurse respond when asked about when a female should begin having a Pap smear? Every year beginning at age 30 years Every 3 years beginning at age 21 years Every 3 years beginning at age 18 years if sexually active Every year beginning at the onset of menarche and continuing until menopause

Every 3 years beginning at age 21 years A Pap test (Pap smear) should be done at least once every 3 years at the age of 21 years regardless of when a woman becomes sexually active. Women 65 years or older may stop having Pap tests after having no abnormal Pap test results for the previous 2 years.

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is at the greatest risk for: hemorrhage. infection. urinary retention. thrombophlebitis.

hemorrhage. Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention than with a normally implanted placenta. There is no greater risk for thrombophlebitis than with a normally implanted placenta.

A client, prescribed which class of antidepressantive medication should be monitored for the development of premature ejaculation? Monoamine oxidase (MAO) inhibitors Tricyclic antidepressants Atypical antipsychotics selective serotonin reuptake inhibitor (SSRI) antidepressants

selective serotonin reuptake inhibitor (SSRI) antidepressants Treatments include antidepressants in the SSRI category. Conversely, pharmacotherapy may cause erectile dysfunction, and medications may need to be evaluated for change or dose reduction. The other options are not used for premature ejaculation.DIF: Cognitive Level: Apply (Application)REF: page 21TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to: change the woman's position. stop the Pitocin. elevate the woman's legs. administer oxygen via a tight mask at 8 to 10 L/min.

stop the Pitocin. The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.

The nurse is caring for a 26-yr-old patient who is being discharged after an induced abortion. Which statement should the nurse include in discharge teaching? "Avoid sexual intercourse for 2 weeks." "Heavy bleeding is expected for 24 hours." "A temperature of 101° F (38.9° C) is normal" "Birth control pills should not be taken for 30 days."

"Avoid sexual intercourse for 2 weeks." After an abortion, teach the patient to avoid intercourse for 2 weeks. Contraception can be started the day of the procedure. Symptoms of possible complications include a fever and abnormal vaginal bleeding. These symptoms should be reported immediately.

A client is crying after undergoing dilation and curettage after an early miscarriage (spontaneous abortion). Which response would the nurse give? "This must be a very difficult experience for you to deal with." "You'll have other children to take the place of the child you lost." "Of course you're sad now, but at least you know you can get pregnant." "I know how you feel, but when a woman miscarries, it's usually for the best."

"This must be a very difficult experience for you to deal with." Saying that this must be a difficult experience acknowledges the validity of the client's grief and provides the client an opportunity to talk if she wishes. Other children cannot and should not be substituted for a lost fetus. Getting pregnant is not the issue; this statement belittles the lost fetus. The nurse cannot know how the client feels. Stating that a miscarriage is for the best is patronizing and diminishes the significance of the lost fetus.

Which is prevented by providing warm, humidified oxygen to a preterm infant? Apnea Cold stress Respiratory distress Bronchopulmonary dysplasia

Cold stress By warming and humidifying oxygen, the nurse will prevent cold stress and drying of the mucosa. Apnea and bronchopulmonary dysplasia are not associated with the administration of oxygen that is not warmed or humidified. Respiratory distress can develop in a preterm infant as a result of the cold stress.

What action should be recommended to a woman recovering from surgical repair of a fistula? Douche daily to prevent postoperative infection. Remove and cleanse her pessary on a daily basis. Resume normal activity to prevent adhesion formation. Ensure that she does not place stress on the repaired area.

Ensure that she does not place stress on the repaired area. After surgical repair of a fistula, the patient should avoid placing stress on the repaired region. Normal activity is not resumed until significant healing has occurred. Douching is contraindicated, and pessaries are used to treat prolapses, not fistulas.

Which statement is most likely to be associated with a breech presentation? Least common malpresentation Descent is rapid Diagnosis by ultrasound only High rate of neuromuscular disorders

High rate of neuromuscular disorders Breech is the most common malpresentation affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as is the fetal head. Diagnosis is made by abdominal palpation and vaginal examination. It is confirmed by ultrasound. Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus.

Because of the risks, a 50-yr-old patient does not want hormone replacement therapy for perimenopausal symptoms. She asks the nurse how to minimize hot flashes and night sweats. What should the nurse recommend first? Increase warmth to avoid chills. Good nutrition to avoid osteoporosis Vitamin B complex and vaginal lubrication Keep the bedroom cool and limit alcohol use.

Keep the bedroom cool and limit alcohol use. To avoid hot flashes and sweating at night, decrease heat production with a cool environment, limit caffeine and alcohol, and practice relaxation techniques. Heat loss may be facilitated with increased circulation in the room, avoidance of heavy bedding, and wearing loose-fitting clothes. Warmth will facilitate hot flashes. Nutrition, vitamin B complex, and vaginal lubrication will help with other complications of perimenopause but not hot flashes and sweating at night.

The nurse is caring for an infant who is suspected to have neonatal sepsis. Which neonatal risk factor for an infant with suspected neonatal sepsis would the nurse expect to observe? Large for gestational age (LGA) and an infant of a diabetic mother Small for gestational age (SGA) and intrauterine growth restriction Singleton gestation and female Multiple gestation and low birth weight

Multiple gestation and low birth weight Large for gestational age (LGA) and infant of a diabetic mother are not neonatal risk factors. Small for gestational age (SGA) and intrauterine growth restriction are not neonatal risk factors. Singleton and female are not neonatal risk factors. Neonatal risk factors include multiple gestation and low birth weight.

The nurse is caring for a 25-yr-old patient who has polycystic ovary syndrome (PCOS). When preparing the teaching plan, which classic manifestation should the nurse associate with severity of symptoms and infertility? Obesity Hirsutism Amenorrhea Irregular menstrual periods

Obesity Obesity has been associated with the severity of symptoms such as excess androgens, oligorrhea, amenorrhea, and infertility. This knowledge will affect the teaching the nurse does for this patient to prevent cardiovascular disease and abnormal insulin resistance. Hirsutism, amenorrhea, and irregular menstrual periods are not associated with the severity of the symptoms.

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. Which action would the nurse take after obtaining the fetal heart rate and maternal vital signs? Teach the client how to push with each contraction. Provide the client with comfort measures for relaxation. Prepare to have the client's blood typed and cross-matched. Encourage the client to perform patterned, paced breathing.

Provide the client with comfort measures for relaxation. The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation. The client is in early first-stage labor; pushing commences during the second stage. There is no evidence that the client's bleeding is excessive or unexpected and that a transfusion will be needed. Patterned, paced breathing should be used in the transition phase, not the early phase of the first stage of labor.

The nurse is caring for an infant born at 28 weeks of gestation. Which complication could the nurse expect to observe during the course of the neonate's hospitalization? (Select all that apply.) Polycythemia Respiratory distress syndrome Meconium aspiration syndrome Periventricular hemorrhage Persistent pulmonary hypertension Patent ductus arteriosus

Respiratory distress syndrome Periventricular hemorrhage Patent ductus arteriosus Respiratory distress syndrome, periventricular hemorrhage, and a patent ductus arteriosus are common complications with preterm infants. Polycythemia, meconium aspiration syndrome, and persistent pulmonary hypertension are complications of postmaturity.

The nurse is providing teaching to a group of perimenopausal women. Which herbs and supplements would the nurse include in a discussion about effective alternative therapies for menopausal symptoms? (Select all that apply.) Soy Garlic Gingko Vitamin A Cinnamon Black cohosh

Soy Black cohosh There is good scientific evidence that soy is useful in decreasing menopausal hot flashes and that black cohosh is safe to use for up to 6 months to decrease menopausal symptoms. Garlic, gingko, vitamin A, and cinnamon do not affect menopausal symptoms.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: birth injury. hypocalcemia. hypoglycemia. seizures.

hypoglycemia. This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis. This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia.

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: bleeding. intense abdominal pain. uterine activity. cramping.

intense abdominal pain. Bleeding may be present in varying degrees for both placental conditions. Pain is absent with placenta previa and may be agonizing with abruptio placentae. Uterine activity may be present with both placental conditions. Cramping is a form of uterine activity that may be present in both placental conditions.

The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: (Select all that apply.) passenger. placenta. passageway. psychologic response. powers. position.

passenger. passageway. psychologic response. powers. position. Five factors affect the process of labor and birth. These are easily remembered as the five Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response.

The primary health care provider instructs the nurse to apply an emollient to an infant. During assessment, the nurse finds that the neonate is a preterm infant and has a body weight of 900 g. Which is the appropriate nursing intervention in this situation? Administer intravenous fluids before applying emollient. Monitor for coagulase-negative staphylococcal infection. Avoid applying emollient to dry, flaking, and fissured areas on the skin. Hold applying emollient and recheck with the primary health care provider.

Monitor for coagulase-negative staphylococcal infection. Emollients can cause coagulase-negative staphylococcal infection in a preterm infant who weighs 900 g or less. Intravenous fluids do not increase the effectiveness of the emollients, so there is no need to administer intravenous fluids before applying the emollient. Emollients effectively reduce dry, flaking, and fissured areas on the infant's skin. Emollients are not contraindicated in preterm infants, so there is no need to hold application or recheck with the primary health care provider.

Which complication of prematurity would the nurse monitor for in a 6-day-old preterm infant in the neonatal intensive care unit? Meconium ileus Duodenal atresia Imperforate anus Necrotizing enterocolitis

Necrotizing enterocolitis Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa related to several factors (e.g., prematurity, hypoxemia, high-solute feedings); it involves shunting of blood from the gastrointestinal tract, decreased secretion of mucus, greater permeability of the mucosa, and increased growth of gas-forming bacteria, eventually resulting in obstruction. NEC usually manifests 4 to 10 days after birth. Meconium ileus occurs within the first 24 hours when the newborn cannot pass any stool. It is not related to the development of NEC; it is a complication of cystic fibrosis. Duodenal atresia is a congenital defect that occurs early in gestation and is present at birth. Imperforate anus is an anorectal malformation that results in the absence of an external anal opening; it is present at birth.

You are interviewing Lance, a 31-year-old patient who has been referred to the sexual disorders clinic by his primary care provider. A client describing his problem states, "I can have an orgasm, no problem. It just happens way too soon." This descriptions support what form of sexual dysfunction? Erectile disorder Premature ejaculation Delayed ejaculation Male hypoactive sexual desire disorder

Premature ejaculation In premature ejaculation, a man persistently or recurrently achieves orgasm and ejaculation before he wishes to. Erectile disorder (also called erectile dysfunction and impotence) refers to failure to obtain and maintain an erection sufficient for sexual activity. In delayed ejaculation, a man achieves ejaculation during coitus only with great difficulty. Male hypoactive sexual desire disorder is characterized by a deficiency or absence of sexual fantasies or desire for sexual activity.DIF: Cognitive Level: Understand (Comprehension)REF: page 12TOP: Nursing Process: DiagnosisMSC: NCLEX: Psychosocial Integrity

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? The fetal presenting part is 1 cm above the ischial spines. Effacement is 4 cm from completion. Dilation is 50% completed. The fetus has achieved passage through the ischial spines.

The fetal presenting part is 1 cm above the ischial spines. Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

A client starts to cry and will not touch her infant when she enters the neonatal intensive care unit (NICU) and sees her preterm infant for the first time. Which interpretation of this behavior would most likely be correct? Incomplete attachment Reaction to the environment Expected detachment behavior Typical reaction to the situation

Typical reaction to the situation Crying in this situation is a typical response; it is expected that the mother will be frightened about touching her small preterm infant. The nurse would provide support and encourage the mother to seek contact with the infant. This is not incomplete attachment but fear in a difficult situation. The reaction to the infant is more complex than merely fear of the NICU. This behavior indicates apprehension in a difficult situation; it is not a detachment behavior.

The nurse knows that the second stage of labor, the active descent phase, has begun when: the amniotic membranes rupture. the cervix cannot be felt during a vaginal examination. the woman experiences a strong urge to bear down. the presenting part is below the ischial spines.

the woman experiences a strong urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. During the active descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation.

Nurses can advise their patients that which of these signs precede labor? (Select all that apply.) A return of urinary frequency as a result of increased bladder pressure. Persistent low backache from relaxed pelvic joints. Stronger and more frequent uterine (Braxton Hicks) contractions. A decline in energy, as the body stores up for labor. Uterus sinks downward and forward in first-time pregnancies.

A return of urinary frequency as a result of increased bladder pressure. Persistent low backache from relaxed pelvic joints. Stronger and more frequent uterine (Braxton Hicks) contractions. After lightening a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term.

A client is being shown her preterm infant in the neonatal intensive care unit (NICU) for the first time. The client immediately starts to cry and refuses to touch her baby. Which situation would this behavior represent? A typical detachment behavior An incomplete bonding behavior An expected reaction to the situation A negative reaction to the NICU environment

An expected reaction to the situation Crying in this situation is a typical response. It is not unusual to be frightened about touching a small preterm infant, and the nurse would provide support while encouraging the mother to do so. Bonding does not involve a detachment behavior phase; the behavior indicates apprehension in a difficult situation. An incomplete bonding behavior is not incomplete bonding but an expression of fear in a difficult situation. The negative reaction to the NICU environment is more complex than mere fear of the NICU.

A woman who is infertile is diagnosed with primary ovarian failure. Which fertility medication regimen would the nurse identify as being used to treat infertility? Clomiphene Menotropins Estrogens Choriogonadotropin alfa

Estrogens Exogenous administration of estrogens or progestins is used to treat infertility associated with primary ovarian failure. The administration of clomiphene, menotropins, and choriogonadotropin alfa cannot stimulate the ovaries to increase the levels of estrogens or progestins. View Topics

A client reports irregular menses, weight gain, and difficulty in conceiving. The client is found to have low hormone levels and is prescribed infertility medications. Which nursing interventions would be beneficial to this client? Select all that apply. One, some, or all responses may be correct. Monitor vital signs. Recommend the self-administration of oral medications. Recommend the long-term use of indomethacin orally. Encourage the client to track her medications in a journal. Administer oral medications to the client when the client wakes up, along with six glasses of water.

Monitor vital signs. Recommend the self-administration of oral medications. Encourage the client to track her medications in a journal. The nurse would monitor the client's vital signs to minimize the risk of hypotension. Journal tracking of medication helps ensure the regular administration of medications. Self-administration of oral medications at home should be encouraged, and proper instructions regarding the administration should be provided to ensure rational use of the medications. The nurse would not advise the long-term oral use of indomethacin because it may cause birth defects. The administration of oral medications upon rising with six glasses of water is the nursing intervention for administration of oral bisphosphonates in the treatment of osteoporosis.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? Encourage her to empty her bladder. Decrease her intravenous (IV) rate to a keep vein-open rate. Turn the woman to the left lateral position or place a pillow under her hip. No action is necessary since a decrease in the woman's blood pressure is expected.

Turn the woman to the left lateral position or place a pillow under her hip. Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The intravenous (IV) rate should be kept at the current rate or increased to maintain the appropriate perfusion. Turning the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor's or nurse midwife's instruction. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.

A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: counterpressure against the sacrum. pant-blow (breaths and puffs) breathing techniques. effleurage. biofeedback.

counterpressure against the sacrum. Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: progressive uterine contractions with cervical change. lightening. rupture of membranes. passage of the mucous plug (operculum).

progressive uterine contractions with cervical change. Regular, progressive uterine contractions that increase in intensity and frequency are the definitive signs of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucous plug is a premonitory sign indicating that the onset of labor is getting closer.

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: the woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. having the woman point her toes reduces leg cramps. the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.

the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor because of a number of potentially unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain.

Which nursing action is indicated when providing immediate care for a female patient who is a victim of a sexual assault? Administering a pregnancy test Monitoring of the patient's vital signs Providing emotional and nonjudgmental support Ensuring the patient is left alone whenever possible

Providing emotional and nonjudgmental support Many sexual assault survivors need emotional and nonjudgmental support following the assault. A pregnancy test is premature, and the patient should not be left alone. There is rarely a specific indication for close monitoring of vital signs unless the extent of physical injury indicates a need.

Which statement provides accurate information regarding transvestic disorder? Most people with this disorder are homosexual. Only men are diagnosed with transvestic disorder. Sexual orientation has no bearing on transvestic disorder. Transvestic behavior develops in middle adulthood.

Sexual orientation has no bearing on transvestic disorder. Unlike in gender dysphorias, in transvestic disorder there are no sexual orientation issues, and people with transvestic disorder do not desire a sex change. Transvestites are usually heterosexual. Although more common in men, women are also diagnosed with transvestic disorder. Transvestic disorder usually develops early in life.DIF: Cognitive Level: Apply (Application)REF: page 36TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action is to: listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. continue to observe and make no changes until the saturations are 75%. continue with the admission process to ensure that a thorough assessment is completed. notify the parents that their infant is not doing well.

listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. These are appropriate nursing interventions to assist in optimal O2 saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. This is not appropriate. Further assessment and intervention are warranted before determination of fetal status.

A 60-yr-old woman comes to the clinic reporting unexpected bleeding. What statement should the nurse use regarding diagnosing the cause of bleeding? "It is probably the end of menopause." "A Pap smear is used to diagnose endometrial cancer." "A hysterectomy may be indicated to treat the bleeding." "An endometrial biopsy will help determine the cause of bleeding."

"An endometrial biopsy will help determine the cause of bleeding." With unexpected bleeding in a postmenopausal woman, an endometrial biopsy should be done to exclude or diagnose endometrial cancer. The abnormal bleeding should not be ignored just because she is postmenopausal. A hysterectomy with bilateral salpingo-oophorectomy with lymph node biopsies will be done to treat endometrial cancer if diagnosed. A Pap smear will not diagnose endometrial cancer unless it has spread to the cervix.

The nurse provides medication teaching for a 30-yr-old woman who is prescribed clomiphene (Clomid). Which patient statement is most important for the nurse to clarify? "Hormone production and release will be increased." "I should avoid intercourse while taking this medication." "This medication will stimulate my ovaries to produce eggs." "This drug is like natural estrogen and is used to treat infertility."

"I should avoid intercourse while taking this medication." Clomiphene is an oral medication administered for infertility. The medication is a selective estrogen-stimulation modulator that stimulates ovulation, making pregnancy after intercourse or artificial insemination more likely. The drug increases gonadotropin-releasing hormone production. In addition, the release of the follicle-stimulating hormone and luteinizing hormone is increased.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: "Do not worry about it. You will do fine." "It is normal to be anxious about labor. Let us discuss what makes you afraid." "Labor is scary to think about, but the actual experience is not." "You may have an epidural. You will not feel anything."

"It is normal to be anxious about labor. Let us discuss what makes you afraid." This statement negates the woman's fears and is not therapeutic. This statement allows the woman to share her concerns with the nurse and is a therapeutic communication tool. This statement negates the woman's fears and offers a false sense of security. This statement is not true. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.

A 55-yr-old woman diagnosed with endometrial cancer is receiving brachytherapy. The nurse is most concerned if what is observed? Foul-smelling vaginal discharge 5 to 8 liquid stools over a period of 24 hours Using a bedpan instead of a bedside commode or toilet A personal companion is staying in the room for company

A personal companion is staying in the room for company Brachytherapy is internal radiation applied directly to the tumor. Health care providers should limit close contact with the patient to less than 30 minutes/day. Internal radiation causes the destruction of cells and results in a foul-smelling vaginal discharge. Internal radiation may cause systemic reactions such as nausea, vomiting, diarrhea, and malaise. The patient receiving brachytherapy is placed in a lead-lined private room and on absolute bed rest.

A 23-yr-old woman admitted with a possible ectopic tubal pregnancy reports sudden intense pelvic pain radiating to the left shoulder. Which action by the nurse should receive the highest priority? Observe the amount of vaginal bleeding every 15 minutes for 1 hour. Check the vital signs and immediately notify the health care provider. Administer the prescribed pain medication and reassess in 30 minutes. Assess the fetal heart tones and determine the presence of fetal movement.

Check the vital signs and immediately notify the health care provider. A ruptured ectopic pregnancy may produce pelvic or abdominal pain and vaginal bleeding. If the tube ruptures, the pain is intense and may be referred to the shoulder. External vaginal bleeding may not be an accurate indicator of actual blood loss. Vital signs should be monitored closely along with observation for signs of shock. A ruptured ectopic pregnancy is an emergency because of the risk of hemorrhage and hypovolemic shock. The patient may need a blood transfusion and IV fluid therapy. In addition, the patient will need emergency surgery. Fetal assessment is not indicated for an ectopic pregnancy.

The nurse feels uncomfortable talking with a young male client about his sexual problem. Which action should the nurse take? Ask another nurse to take over the interview so you don't project your feelings onto the patient. Pause the interview and take time to gather your thoughts and do positive self-talk. Continue the interview using an appropriate professional tone and matter-of-fact approach. Ask Lance whether he would feel more comfortable speaking with a physician about his problem.

Continue the interview using an appropriate professional tone and matter-of-fact approach. Remembering your position as a professional and addressing the topics in a tone and manner appropriate of a professional will increase your comfort, along with the patient's. The response in the first option would be confusing to the patient and does not address your feelings or work to resolve them. Pausing the interview would not be appropriate because self-assessment is best done before patient interaction. Asking the patient whether he would feel more comfortable speaking with a physician projects your feelings of being uncomfortable onto the patient and does not carry out your professional role and responsibility.DIF: Cognitive Level: Apply (Application)REF: page 2TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

Which characteristic is associated with false labor contractions? Lead to cervical change Decrease in intensity with ambulation Regular pattern of frequency established Progressive in terms of intensity and duration

Decrease in intensity with ambulation False labor does not lead to changes in the cervix. Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. A regular pattern of frequency is a sign of true labor. A progression of intensity and duration indicates true labor.

A 58-yr-old woman is 1-day postoperative after an abdominal hysterectomy. Which intervention should the nurse perform to prevent VTE? Place the patient in a high Fowler's position. Provide pillows to place under the patient's knees. Encourage the patient to change positions frequently. Teach the patient deep breathing and coughing exercises.

Encourage the patient to change positions frequently. The patient should be encouraged to change positions frequently and ambulate to prevent venous stasis. The high Fowler's position and pressure under the knees should be avoided to prevent VTE. Deep breathing and coughing are therapeutic exercises but do not directly address the risk of VTE.

The patient at the clinic reports abdominal bloating, depression, and irritability related to premenstrual syndrome. What should the nurse recommend initially? (Select all that apply.) Take diuretics. Exercise regularly. Take antidepressants. Take antianxiety agents. Increase pork, chicken, and milk intake. Consider psychological counseling to resolve symptoms.

Exercise regularly. Increase pork, chicken, and milk intake. The nurse can recommend regular exercise to help manage stress, elevate the mood, and have a relaxing effect. Eating foods rich in vitamin B6 (pork, milk, and legumes) and tryptophan (dairy and poultry) will promote serotonin production and improve symptoms. Diuretics, antidepressants, and antianxiety agents are not prescribed unless symptoms persist or interfere with daily functioning. Psychological counseling does not address physiological symptoms, but it may improve coping mechanisms.

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What findings indicate that preterm labor may be occurring? (Select all that apply.) History of preterm labor experience with a prior pregnancy. Irregular, mild uterine contractions are occurring every 12 to 15 minutes. Fetal fibronectin is present in vaginal secretions. The cervix is effacing and dilated to 2 cm. Fetal heart rate of 150 beats/minute

History of preterm labor experience with a prior pregnancy. The cervix is effacing and dilated to 2 cm. A significant risk factor for preterm birth is a preterm birth experience with a prior pregnancy. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor, such as cervical changes. Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Fetal heart rate is normal.

What should the nurse emphasize when teaching a woman diagnosed with pelvic inflammatory disease (PID)? The importance of contraception Manifestations of further infection The importance of maintaining hygiene Benefits of hormone replacement therapy (HRT)

Manifestations of further infection PID frequently progresses to serious infection of the reproductive structures. The diagnosis does not present a particular need for contraception or specific hygiene measures. HRT is not used to treat PID.

A client who is 25 weeks' pregnant and who is being treated with atenolol reports labor pain. Which medication would the nurse anticipate incorporating into the plan of care? Sucralfate Nifedipine Indomethacin Dexamethasone

Nifedipine Nifedipine inhibits myometrial activity by blocking calcium reflux. This action helps reduce preterm labor. Indomethacin is commonly used to treat preterm labor. However, concomitant use of atenolol and indomethacin may increase maternal and fetal risk. Dexamethasone is administered if neither indomethacin nor nifedipine is effective. Sucralfate is used to protect the stomach from gastrointestinal issues associated with indomethacin.

What should the nurse include when teaching about early detection of ovarian cancer? Report any unusual vaginal bleeding. Use estrogen with progestin for menopause. Obtain annual bimanual pelvic examinations.Correct Answer Receive a preventive bilateral oophorectomy.

Obtain annual bimanual pelvic examinations. Because it is difficult for a patient to detect early clinical indicators of ovarian cancer, the best method of early detection is to have a yearly bimanual pelvic examination to palpate for an ovarian mass. Although pelvic or vaginal bleeding should be reported soon after it occurs, this rarely occurs with ovarian cancer and is not an early symptom. Oral contraceptives may be used or a preventive bilateral oophorectomy may be done to reduce the risk, but they would not be done to detect early ovarian cancer.

The nurse is planning to teach the parents of a preterm infant about the infant's nutritional needs. Which nutrients are required in greater quantities in a preterm infant than a full-term one? Proteins Carbohydrates Vitamins A, D, E, and K Calcium and phosphorus

Proteins Proteins are needed for tissue building; therefore the preterm infant's need for protein is greater than the full-term infant's. Carbohydrates are not needed in greater quantities by the preterm infant than by the full-term infant. Vitamins A, D, E, and K are fat-soluble vitamins; all of these vitamins are needed, but the B vitamins, found in proteins, are most important for the preterm infant. Although minerals are needed for electrolyte balance, they are not the priority nutrient for a preterm newborn.

A student nurse in the emergency department is assigned to care for a client convicted of the sexual abuse of a child. The student is repulsed by the client because of the nature of his crime and doesn't know how to care for the client under these circumstances. What action should the student nurse take? Refuse the assignment because personal feelings will prevent the student from providing good care. Talk with a faculty member or an experienced nurse in the emergency department. Perform the activities of care but not engage in conversation with the client. Suggest to the client that he request a different nurse.

Talk with a faculty member or an experienced nurse in the emergency department. Nurses may experience distress when providing care for someone who engages in what they view as objectionable, or even reprehensible, acts. This is sometimes compounded by knowing someone who was a victim or having been victimized ourselves. Talking with a faculty member, a nurse mentor, or someone at a mental health clinic can be helpful and important and may even result in better personal understanding and coping. Refusing an assignment is not an option. Performing the activities of care but not engaging in conversation does not appropriately or fully care for the patient. Telling the patient how she feels would be unprofessional and inappropriate, and is putting the burden of our own feelings onto the patient.DIF: Cognitive Level: Analyze (Analysis)REF: page 395TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

With regard to the classification of neonatal bacterial infection, nurses should be aware that: congenital infection progresses slower than health care-associated infection. health care-associated infection can be prevented by effective handwashing. infections occur with about the same frequency in boy and girl infants, although female mortality is higher. the clinical sign of a rapid, high fever makes infection easier to diagnose.

health care-associated infection can be prevented by effective handwashing. Congenital (early onset) infections progress more rapidly than health care-associated (late onset) infections. Handwashing is an effective preventative measure for late onset (health care associated) infections because these infections come from the environment around the infant. Early onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract. Congenital (early onset) infections progress more rapidly than health care-associated (late onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Congenital (early onset) infections progress more rapidly than health care-associated (late onset) infections. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult. Congenital (early onset) infections progress more rapidly than health care-associated (late onset) infections.

The nurse is caring for a couple during their initial visit to a fertility clinic after being unable to conceive for 2 years. Which assessment questions would be appropriate to determine an alternate cause of infertility? "Do you use any lubrication during intercourse?" "Can both of you reach orgasm at the same time?" "What type of birth control did you use in the past?" "Are you consistent in the manner in which you have intercourse?"

"Do you use any lubrication during intercourse?" Some lubricants act as a spermicide; they should be avoided, or only a recommended lubricant should be used. A female orgasm is not necessary for conception; asking about simultaneous orgasms is not a relevant question. The type of birth control before the couple began trying to conceive 2 years ago is not relevant at this time. Consistency in the manner of intercourse usually is not relevant to conception, although a change in position may be recommended.

A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse? "My husband and I have agreed that my sister will be my coach since he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK." "We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor." "We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born." "We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage."

"We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage." These are acceptable requests during labor and delivery. These are acceptable requests during labor and delivery. These are acceptable requests during labor and delivery. Since monitoring is essential to assess fetal well-being, it is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low risk pregnancy and as long as labor is progressing normally.

A 45-year-old client is scheduled to undergo a hysterectomy and expresses concern because she has heard from friends that she will experience severe symptoms of menopause after surgery. Which response would the nurse give? "You're right, but there are medicines you can take that will ease the symptoms." "Sometimes that happens in women of your age, but you don't need to worry about it right now." "You should probably talk to your surgeon, because I am not allowed to discuss this with you." "Women may experience symptoms of menopause if their ovaries are removed with their uterus."

"Women may experience symptoms of menopause if their ovaries are removed with their uterus." A hysterectomy involves only removal of the uterus. The ovaries, which secrete estrogen and progesterone, are not removed. Menopause will not be precipitated but will occur naturally. Surgical menopause is precipitated by the removal of the ovaries, not the uterus. It would be incorrect to state that there are medicines to help with menopause because menopause would not be caused by the surgery the client will have. When the ovaries are removed, an older woman might have less severe symptoms than a younger woman; however, in this instance the ovaries are not removed. Telling the client that she needs to talk to her surgeon does not answer the question. The nurse should serve as a resource.

The nurse in the birthing room is assessing a newborn. Which characteristic would be assigned an Apgar value of 2? A strong cry A heart rate of 90 beats/min Slight flexion of legs and arms Pink body and blue extremities

A strong cry A strong cry indicates effective respiratory function and is assigned a value of 2. The heart rate should be more than 100 beats/min; therefore a pulse of 90 beats/min is assigned a value of 1. If flexion of the arms and legs is slight and movement is diminished, a value of 1 is assigned. A value of 1 is assigned when the body is pink and the extremities are blue.

The emergency department nurse is assessing a pregnant trauma victim who just arrived at the hospital. What are the nurse's MOSTappropriate actions? (Select all that apply.) Place the patient in a supine position. Assess for point of maximal impulse at fourth intercostal space. Collect urine for urinalysis and culture. Frequent vital sign monitoring. Assist with ambulation to decrease risk of thrombosis.

Assess for point of maximal impulse at fourth intercostal space. Collect urine for urinalysis and culture. Frequent vital sign monitoring. Passive regurgitation may occur if patient is supine, leading to high risk for aspiration. Placental perfusion is decreased when the patient is in a supine position as well. The heart is displaced upward and to the left in pregnant patients. During pregnancy, there is dilation of the ureters and urethra, and the bladder is displaced forward placing the pregnant trauma patient at higher risk for urinary stasis, infection, and bladder trauma. The trauma patient can suffer blood loss and other complications, necessitating frequent monitoring of vital signs. While the pregnant patient is at risk for thrombus formation, the patient must be cleared by the health care provider before ambulating. The pregnant trauma patient is at higher risk for pelvic fracture, and therefore this condition must be ruled out first as well.

The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? (Select all that apply.) Decreased urinary output and irritability Transient headache and +1 proteinuria Ankle clonus and epigastric pain Platelet count of less than 100,000/mm3 and visual problems Seizure activity and hypotension

Decreased urinary output and irritability Ankle clonus and epigastric pain Platelet count of less than 100,000/mm3 and visual problems Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of severe eclampsia.

As part of an infertility workup involving both partners, a male client is to have a semen analysis. Which instruction would the nurse give him? Obtain the specimen upon awakening. Use a condom to collect the semen specimen. Ejaculate at least 4 hours before collection to ensure a pure specimen. Deliver the specimen to the laboratory within 2 hours of obtaining it.

Deliver the specimen to the laboratory within 2 hours of obtaining it. Delivering the specimen within 2 hours is necessary to keep the sperm viable for determining sperm count and viability. The specimen can be collected at any time. Rubber solvents, preservatives, or spermicides in a condom may affect the semen specimen. Usual instructions are to not ejaculate for 2 to 3 days before the collection.

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How would the nurse explain the increased risk for hypothermia in preterm infants? Have a smaller body surface area than full-term newborns Lack the subcutaneous fat that usually provides insulation Perspire excessively, causing a constant loss of body heat Have a limited ability to produce antibodies against infections

Lack the subcutaneous fat that usually provides insulation Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and has little of this insulating layer. The preterm infant has a relatively larger surface area per body weight than does a term infant. Preterm infants do not shiver or perspire. Depressed antibody production is unrelated to maintenance of body temperature.

For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse? Fetal heart rate of 116 beats/min Cervix dilated 2 cm and 50% effaced Score of 8 on the biophysical profile One fetal movement noted in 1 hour of assessment by the mother

One fetal movement noted in 1 hour of assessment by the mother A fetal heart rate of 116 beats/min is a normal finding at 42 weeks of gestation. Cervical dilation of 2 cm with 50% effacement is a normal finding in a 42-week gestation woman. A score of 8 on the biophysical profile (BPP) is a normal finding in a 42-week gestation pregnancy. Self-care in a postterm pregnancy should include performing daily fetal kick counts 3 times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation.

Which laboratory test result would be a cause for concern if exhibited by an Rh-positive newborn 12 hours after birth? Direct Coombs': Negative Hematocrit (Hct): 58% and hemoglobin (Hgb): 18 g/dL Blood glucose level: 55 mg/dL Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratory (VDRL): Reactive

Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratory (VDRL): Reactive The negative Coombs' indicates absence of antibodies against Rh-positive blood. Hgb is between 15 and 20 g/dL, and Hct is between 43% and 61%. The blood glucose level should be 45 mg/dL or higher. A reactive rapid plasma reagin/venereal diseases research laboratory (RPR/VDRL) indicates exposure to syphilis while in utero.

The nurse is caring for a preterm infant who is receiving oxygen therapy. Which would the nurse do to prevent retinopathy of prematurity (ROP)? Cover the neonate's eyes with a shield. Place the neonate in an elevated side-lying position. Assess the neonate every hour with a pulse oximeter. Support the neonate's oxygen saturation while providing minimal FiO 2.

Support the neonate's oxygen saturation while providing minimal FiO 2. ROP is a complex disease of the preterm infant; hyperoxemia is one of the numerous causes implicated. Oxygen therapy is maintained at the lowest level necessary to support respiratory status. If the oxygen concentration needs to be increased to maintain life, ROP may not be preventable. Using a shield over the neonate's eyes will not prevent the development of ROP, nor does positioning or assessment of the neonate every hour with a pulse oximeter alone. If the pulse oximetry results are within an acceptable range, the oxygen concentration may be reduced.

Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? FHR does not change as a result of fetal activity. Average baseline rate ranges between 100 and 140 beats/min. Mild late deceleration patterns occur with some contractions. Variability averages between 6 and 10 beats/min.

Variability averages between 6 and 10 beats/min. Fetal heart rate (FHR) should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings. Variability indicates a well oxygenated fetus with a functioning autonomic nervous system.

In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information? "Because this is a repeat procedure, you are at the lowest risk for complications." "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." "Because this is your second cesarean birth, you will recover faster." "You will not need preoperative teaching because this is your second cesarean birth."

"Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." This statement is not accurate. Maternal and fetal risks are associated with every cesarean section. This statement is the most appropriate. This statement is not accurate. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed regardless of whether the client has already had this procedure.

The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions? "I will not experience mood swings since I was only at 10 weeks of gestation." "I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months." "I should eat foods that are high in iron and protein to help my body heal." "I should expect the bleeding to be heavy and bright red for at least 1 week."

"I should eat foods that are high in iron and protein to help my body heal." After a miscarriage a woman may experience mood swings and depression from the reduction of hormones and the grieving process. Sexual intercourse should be avoided for 2 weeks or until the bleeding has stopped and should avoid pregnancy for 2 months. A woman who has experienced a miscarriage should be advised to eat foods that are high in iron and protein to help replenish her body after the loss. The woman should not experience bright red, heavy, profuse bleeding; this should be reported to the health care provider.

A pregnant woman presents to the emergency department complaining of persistent nausea and vomiting. She is diagnosed with hyperemesis gravidarum. The nurse should include which information when teaching about diet for hyperemesis? (Select all that apply.) Eat three larger meals a day. Eat a high-protein snack at bedtime. Ice cream may stay down better than other foods. Avoid ginger tea or sweet drinks. Eat what sounds good to you even if your meals are not well-balanced.

Eat a high-protein snack at bedtime. Ice cream may stay down better than other foods. Eat what sounds good to you even if your meals are not well-balanced. The diet for hyperemesis includes: Avoid an empty stomach. Eat frequently, at least every 2 to 3 hours. Separate liquids from solids and alternate every 2 to 3 hours.Eat a high-protein snack at bedtime.Eat dry, bland, low-fat, and high-protein foods. Cold foods may be better tolerated than those served at a warm temperature.In general, eat what sounds good to you rather than trying to balance your meals.Follow the salty and sweet approach; even so-called junk foods are okay.Eat protein after sweets.Dairy products may stay down more easily than other foods.If you vomit even when your stomach is empty, try sucking on a Popsicle.Try ginger tea. Peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8 minutes and add brown sugar to taste.Try warm ginger ale (with sugar, not artificial sweetener) or water with a slice of lemon.Drink liquids from a cup with a lid.

The nurse is caring for a preterm infant who needs to have gavage feedings started and requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for insertion of a nasogastric tube in a preterm infant. Lubricate the tip of the tube with sterile water. Place infant in supine position. Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. Check placement of the NG tube by aspirating gastric contents. Gently insert the NG tube through the mouth or nose.

Lubricate the tip of the tube with sterile water. Place infant in supine position. Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. Check placement of the NG tube by aspirating gastric contents. Gently insert the NG tube through the mouth or nose. The correct steps in the sequence would be:Place infant in supine positionMeasure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xiphoid process and the umbilicusLubricate the tip of the tube with sterile waterGently insert the NG tube through the mouth or noseCheck placement of the NG tube by aspirating gastric contents

The nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. Which is the priority nursing action? Limiting caloric intake to decrease metabolic rate Maintaining the prone position to prevent aspiration Limiting oxygen concentration to prevent eye damage Maintaining a high-humidity environment to promote gas exchange

Maintaining a high-humidity environment to promote gas exchange The moisture provided by the humidity liquefies the tenacious secretions, making gas exchange possible. Caloric intake is increased; the amount, number, and type of feedings are related to the metabolic rate. Infants should be placed in a side-lying rather than a prone position; the prone position is associated with apnea and sudden infant death syndrome. Limiting oxygen concentration to prevent eye damage is not a routine action; the concentration of oxygen depends on the oxygen concentration of the neonate's blood gases.

A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? Place the woman in the knee-chest position. Cover the cord in a sterile towel saturated with warm normal saline. Prepare the woman for a cesarean birth. Start oxygen by face mask.

Place the woman in the knee-chest position. A. The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord.B. If the cord is protruding from the vagina, it may be covered with a sterile towel soaked in saline. Although this is an appropriate intervention, relieving pressure on the cord is the nursing priority.C. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. Cesarean birth is indicated only if cervical dilation is not complete. D. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete. This intervention should be initiated after pressure is relieved on the cord. Not only should the woman be placed in knee-chest position, the nurse may also use her gloved hand or two fingers to lift the presenting part off the cord.

A 41-year-old woman is being seen for an initial visit in the infertility clinic after 3 years of trying to become pregnant. Which test or treatment would the nurse advise her would be done first? A laparoscopy The start of fertility medication A hysteroscopy Semen analysis

Semen analysis Semen analysis is painless, is less costly than other interventions, and provides important information regarding the male partner's fertility. It can be done at the same time that laboratory tests are being done on the female partner to assess her ovulatory function. Fertility medication would not be initiated until an evaluation of ovulatory function had been completed. Simpler evaluations and therapies are completed before more complex efforts such as surgical procedures like laparoscopy and hysteroscopy are performed.

Which activity would help prepare a client to care for her preterm infant who is in the neonatal intensive care unit? She will be encouraged to participate in the infant's care as much as possible. She may watch the care to familiarize herself with the specific routines. She should find someone with preterm care training to help at home for the first week. She will be able to care for the infant in a special nursery for a few days before discharge.

She will be encouraged to participate in the infant's care as much as possible. By participating in her infant's care, the mother will gain confidence in her own ability to meet her infant's needs. Watching the provision of care by others may only increase the client's sense of inadequacy. There is no need for a specialist to care for the infant after discharge. The mother should be involved with infant care as early as possible, not just a few days before discharge.

A female client who is undergoing infertility testing is taught how to examine her cervical mucus. After listening to the instructions, the client says, "That sounds gross. I don't think I can do it." Which conclusion would the nurse make from this statement? The client is unduly fastidious. The client feels that having a baby is not that important. The client may be uncomfortable with performing manual examination of the genitals. The client is afraid that she is the cause of the infertility.

The client may be uncomfortable with performing manual examination of the genitals. Some women find it emotionally stressful to handle their genitals and discharges. The nurse would need to question the client further to determine if this is the case. The nurse does not have data to support whether the client is unduly fastidious. The nurse would not pass judgment on whether or not the client desires having a baby. Although many women in this situation feel that they are the cause of infertility, this has no bearing on either the nurse's instruction or the client's response.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: hypertonia, tachycardia, and metabolic alkalosis. abdominal distention, temperature instability, and grossly bloody stools. hypertension, absence of apnea, and ruddy skin color. scaphoid abdomen, no residual with feedings, and increased urinary output.

abdominal distention, temperature instability, and grossly bloody stools. The infant may display hypotonia, bradycardia, and metabolic acidosis. Some generalized signs of necrotizing enterocolitis (NEC) include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. Hypotension, apnea, and pallor are signs of NEC. Abdominal distention, residual gastric aspirates, and oliguria are signs of NEC.

In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: the pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. there are no physical symptoms associated with fetal alcohol syndrome (FAS) so it may be harder to diagnose. alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. The pattern of growth restriction persists after birth. There are classic physical symptoms associated with the clinical diagnosis of fetal alcohol syndrome (FAS), which are easily recognizable. Some learning problems do not become evident until the child is in school. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.

A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: bloody show. weight gain of 1 to 3 lbs. quickening. fatigue and lethargy.

bloody show. Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct. Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens.

The nurse's priority action when observing early deceleration indicating expected head compression during contractions is to: notify the health care provider. assist with vaginal examination to assess for cord prolapse. change maternal position. assist with amnioinfusion.

change maternal position. The usual priority is as follows:1. Change maternal position (side to side, knee chest).2. Discontinue oxytocin if infusing.3. Administer oxygen at 8 to 10 L/min by nonrebreather face mask.4. Notify physician or nurse-midwife.5. Assist with vaginal or speculum examination to assess for cord prolapse.6. Assist with amnioinfusion if ordered.7. Assist with birth (vaginal assisted or cesarean) if pattern cannot be corrected

On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: describe the finding in the nurse's notes. reposition the woman onto her side. call the physician for instructions. administer oxygen at 8 to 10 L/min with a tight face mask.

describe the finding in the nurse's notes. An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix. These actions would be implemented when nonreassuring or ominous changes are noted.

With regard to systemic analgesics administered during labor, nurses should be aware that: systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. effects on the fetus and newborn can include decreased alertness and delayed sucking. Intramuscular (IM) administration is preferred over IV administration. Intravenous (IV) patient-controlled analgesia (PCA) results in increased use of an analgesic.

effects on the fetus and newborn can include decreased alertness and delayed sucking. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. Intravenous (IV) administration is preferred over intramuscular (IM) administration because the drug acts faster and more predictably. Patient-controlled analgesia (PCAs) result in decreased use of an analgesic.

A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate analgesic for pain control is: fentanyl (Sublimaze). promethazine (Phenergan). butorphanol tartrate (Stadol). nalbuphine (Nubain).

fentanyl (Sublimaze). Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use.

An Rh-negative, 30-year-old gravida 1 para 0 experiences a miscarriage at 10 weeks' gestation. Which action would the nurse anticipate regarding the administration of Rho(D) immune globulin? Administration of one intramuscular microdose (50 mcg) of Rho(D) immune globulin Administration of one intramuscular standard dose (300 mcg) of Rho(D) immune globulin A prescription for one subcutaneous standard dose (300 mcg) of Rho(D) immune globulin A prescription of Rho(D) immune globulin will not be administered because of pregnancy ending during first trimester

Administration of one intramuscular microdose (50 mcg) of Rho(D) immune globulin To prevent production of anti-Rho(D) antibodies in an Rh-negative woman who has been exposed to Rh-positive blood, a microdose of Rho(D) immune globulin (RhoGAM) must be administered intramuscularly because the pregnancy ended in the first trimester. Had the pregnancy ended at 13 weeks' gestation or later, a standard dose of Rho(D) immune globulin would be administered intramuscularly. Rho(D) immune globulin is not administered subcutaneously.

When monitoring a woman in labor who has just received spinal analgesia, the nurse should report which assessment findings to the health care provider? (Select all that apply.) Maternal blood pressure of 108/79 Maternal heart rate of 98 Respiratory rate of 14 breaths/min Fetal heart rate of 100 beats/min Minimal variability on a fetal heart monitor

Fetal heart rate of 100 beats/min Minimal variability on a fetal heart monitor After induction of the anesthetic, maternal blood pressure, pulse, and respirations and fetal heart rate and pattern must be checked and documented every 5 to 10 minutes. If signs of serious maternal hypotension (e.g., the systolic blood pressure drops to 100 mm Hg or less or the blood pressure falls 20% or more below the baseline) or fetal distress (e.g., bradycardia, minimal or absent variability, late decelerations) develop, emergency care must be given.

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: eclamptic seizure. rupture of the uterus. placenta previa. placental abruption.

placental abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa presents with bright red, painless vaginal bleeding. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption.

Fetal well-being during labor is assessed by: the response of the fetal heart rate (FHR) to uterine contractions (UCs). maternal pain control. accelerations in the FHR. an FHR greater than 110 beats/min.

the response of the fetal heart rate (FHR) to uterine contractions (UCs). Fetal well-being during labor can be measured by the response of fetal heart rate (FHR) to uterine contractions (UCs). In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.

With regard to dysfunctional labor, nurses should be aware that: dysfunctional labor typically occurs in women who have a gynecoid pelvis. women who have dysfunctional labor are more likely to deliver via cesarean section. hypertonic uterine dysfunction is more common than hypotonic dysfunction. abnormal labor patterns are most common in older women.

women who have dysfunctional labor are more likely to deliver via cesarean section. Dysfunctional labor is more likely to occur as a result of a structural (pelvic) abnormality. A gynecoid pelvis is considered to be a normal pelvic structure. Women who have dysfunctional labor are more likely to deliver via cesarean section as compared to vaginal delivery. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women younger than 20 years of age.

A pregnant client has two children at home, the first born at 38 weeks' gestation and the second born at 34 weeks' gestation. She has also had one miscarriage, at 18 weeks, and an elective abortion. Which is the correct summary of her obstetric history using the GTPAL system? G5 T1 P1 A2 L2 G4 T2 P2 A1 L4 G2 T3 P3 A2 L1 G3 T2 P1 A3 L3

G5 T1 P1 A2 L2 G (gravida) stands for the total number of pregnancies a client has had. Gravida 5 indicates that this is the client's fifth pregnancy. T (term) stands for the number of neonates born at the expected date of birth. The neonate born at 38 weeks' gestation was born at term. P (preterm) stands for the number of neonates born before the expected date of birth. The neonate born at 34 weeks' gestation was born preterm. An abortion or miscarriage describes the birth of a fetus before 20 weeks' gestation. Both the miscarriage and elective abortion are considered abortions. L (living) stands for the number of living children at the time of assessment. The client has two living children.

A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, and fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, which problem would the nurse suspect? Preterm labor Uterine inertia Placenta previa Abruptio placentae

Placenta previa A nontender uterus and bright-red bleeding are classic signs of placenta previa; as the cervix dilates, the overlying placenta separates from the uterus and begins to bleed. There is no information to indicate that the client is in labor. There is no indication that the client was having contractions that have now ceased. The classic adaptations to abruptio placentae are pain and a rigid boardlike abdomen; dark-red blood may or may not be present.

Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion? Prepare the woman for a dilation and curettage (D&C). Place the woman on bed rest for at least 1 week and reevaluate. Prepare the woman for an ultrasound and blood work. Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month.

Prepare the woman for an ultrasound and blood work. Dilation and curretage (D&C) is not considered until signs of the progress to an inevitable abortion are noted or the contents are expelled and incomplete. Bed rest is recommended for 48 hours initially. Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine if the fetus is alive and within the uterus. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. Which action would the nurse take next? Return the aspirate and withhold the feeding. Discard the aspirate and administer the full feeding. Return the aspirate and administer the full feeding. Discard the aspirate and add an equal amount of normal saline solution to the feeding.

Return the aspirate and administer the full feeding. The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. Recent evidence indicates that aspirates should not be subtracted from the feeding volume, as this reduces energy intake. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance.

The nurse is teaching a student about adhesives to be used for preterm infants. Which statement by the student indicates effective learning? "I should remove the adhesive with solvents or bonding agents." "I should remove the adhesive within 24 hours after application." "I should avoid semipermeable dressings to secure intravenous lines." "I should secure pulse oximeter probes with elasticized dressing material.

"I should secure pulse oximeter probes with elasticized dressing material. Elasticized dressing material can effectively secure pulse oximeter probes or electrodes with minimal skin irritation in preterm infants. Adhesive removers, solvents, or bonding agents may result in skin damage in a preterm neonate. The adhesives are removed using water, mineral oil, or petrolatum. The adhesive should not be removed for at least 24 hours after application. Semipermeable dressings can be used to secure intravenous lines and silicone catheters in a preterm neonate.

After a hysterosalpingo-oophorectomy, a client wants to know whether it would be wise for her to take hormones right away to prevent symptoms of menopause. Which response would the nurse give? "It's best to wait until a few months after surgery because you may not have any symptoms." "Hormone replacement therapy has been associated with increased risk of breast cancer, so it would not be recommended." "You have to wait until symptoms are severe; otherwise the hormones will have no effect." "There are pros and cons to hormone replacement therapy. I will let your primary health care provider know you would like to discuss this."

"There are pros and cons to hormone replacement therapy. I will let your primary health care provider know you would like to discuss this." The use of hormone replacement therapy (HRT) can have benefit to a client who has undergone an oophorectomy. It can prevent menopausal symptoms such as hot flashes and vaginal dryness. It can also increase bone strength. The risks of HRT include an increased risk of breast cancer. The decision to use HRT would involve review of the client's age, medical conditions, and symptoms. The health care provider and client would engage in shared decision-making regarding initiation of HRT. If a client is going to begin HRT, the timing of initiation might depend on the reason it is being used. Stating the HRT will have no effect unless the symptoms are severe is not a true statement.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? The healthy newborn should be taken to the nursery for a complete assessment. After drying, the infant should be given to the mother wrapped in a receiving blanket. Encourage skin-to-skin contact of mother and baby. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.

Encourage skin-to-skin contact of mother and baby. Although this is the practice in many facilities, it is neither evidence based nor supportive of family-centered care. This is a common practice and more family friendly than separating mother and baby; however, ideally the baby should be placed skin to skin. The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. The father or support person is likely anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin and breastfeeding has been initiated.

The nurse is teaching a client who has decreased production of estrogen because of menopause about self-management and prevention of complications. Which actions performed by the client would help reduce the complications? Select all that apply. One, some, or all responses may be correct. Walking for 30 minutes per day Performing weight-bearing activities Dressing warmly in cool or cold weather Urinating immediately after sexual intercourse Keeping within 10 pounds of ideal body weight

Walking for 30 minutes per day Performing weight-bearing activities Urinating immediately after sexual intercourse Because decreased ovarian production of estrogen leads to low bone density, regular exercises are advised, such as walking for 30 minutes per day and performing weight-bearing activities. Decreased ovarian production of estrogen increases the risk of cystitis; therefore, female clients are advised to reduce the risk by urinating immediately after sexual intercourse. Dressing warmly in cool weather would be beneficial to a client with decreased general metabolism because they may have less tolerance to cold. Maintaining body weight within 10 pounds of ideal would be beneficial to a client with decreased glucose tolerance.

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours Active: Moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours Lull: No contractions; dilation stable; duration of 20 to 60 minutes Transition: Very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

Active: Moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

After delivering a healthy baby boy with epidural anesthesia, a woman on the after birth unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.) Keeping the head of bed elevated at all times Administration of oral analgesics Avoid caffeine Assisting with a blood patch procedure Frequent monitoring of vital signs

Administration of oral analgesics Assisting with a blood patch procedure Frequent monitoring of vital signs The nurse should suspect the patient is suffering from a postdural puncture headache (PDPH). Characteristically, assuming an upright position triggers or intensifies the headache, whereas assuming a supine position achieves relief (Hawkins and Bucklin, 2012). Conservative management for a PDPH includes administration of oral analgesics and methylxanthines (e.g., caffeine or theophylline). Methylxanthines cause constriction of cerebral blood vessels and may provide symptomatic relief. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for PDPH. Close monitoring of vital signs is essential.

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? Notify nursery nurse of imminent delivery. Perform a straight cath at this time. Start oxytocin (Pitocin). Notify the primary health care provider immediately (HCP).

Notify the primary health care provider immediately (HCP). Although delivery is a priority, notification of the nursery nurse is not the most important nursing measure at this time. The patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean section may be warranted. Performing a straight cath at this time would not be prudent as it is more likely that a foley catheter will have to be inserted if a cesarean section becomes the mode of delivery. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration, the nurse can reposition the mother, increase intravenous (IV) fluid, and provide oxygen. Also, if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately.

The maternity nurse should notify the health care provider about which assessment findings during labor? (Select all that apply.) Positive urine drug screen Blood glucose level of 78 mg/dL Increased systolic blood pressure during first stage Elevated white blood cell count Oral temperature of 99.8° F Respiratory rate of 10 breaths/min

Positive urine drug screen Blood glucose level of 78 mg/dL Increased systolic blood pressure during first stage Elevated white blood cell count Respiratory rate of 10 breaths/min The health care provider should be alerted to a positive urine drug screen, because certain drugs will have an effect on pain medications that can be safely administered. The respiratory rate usually increases during labor. A rate of 10 is low and needs to be reported. Decreased blood glucose levels (due to exertion and glucose consumption for energy), and increased systolic blood pressure, elevated white blood cell count (due to stress response), and a slightly elevated temperature (up to 100.4° F) are expected findings during labor.

The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? (Select all that apply.) Unstable coronary artery disease Previous cesarean birth Placenta previa Initial blood pressure of 132/87 History of three spontaneous abortions

Unstable coronary artery disease Previous cesarean birth Placenta previa Indications for cesarean birth include:MaternalSpecific cardiac disease (e.g., Marfan syndrome, unstable coronary artery disease)Specific respiratory disease (e.g., Guillain-Barré syndrome)Conditions associated with increased intracranial pressureMechanical obstruction of the lower uterine segment (tumors, fibroids)Mechanical vulvar obstruction (e.g., extensive condylomata)History of previous cesarean birthFetalAbnormal fetal heart rate (FHR) or patternMalpresentation (e.g., breech or transverse lie)Active maternal herpes lesionsMaternal human immunodeficiency virus (HIV) with a viral load of more than 1000 copies/mLCongenital anomaliesMaternal-FetalDysfunctional labor (e.g., cephalopelvic disproportion, "failure to progress" in labor)Placental abruptionPlacenta previaElective cesarean birth (cesarean on maternal request)The blood pressure can be elevated because of pain and is not necessarily a contraindication to vaginal birth until further assessment is completed. Having a history of three spontaneous abortions is not a contraindication to vaginal birth.

A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: uterine contractions occurring every 8 to 10 minutes a fetal heart rate (FHR) of 180 with absence of variability. the client needing to void. rupture of the client's amniotic membranes.

a fetal heart rate (FHR) of 180 with absence of variability. The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. This fetal heart rate (FHR) is nonreassuring. The oxytocin should be immediately discontinued and the physician should be notified. This is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is nonreassuring or the client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the client's membranes have ruptured.

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: either hot or cold applications may provide relief, but they should never be used together in the same treatment. acupuncture can be performed by a skilled nurse with just a little training. hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. therapeutic touch uses handheld electronic stimulators that produce sympathetic vibrations.

hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. The woman and her partner should experiment with massage before labor to see what might work best. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: encourage the woman to breathe more slowly. help the woman breathe into a paper bag. turn the woman on her side. administer a sedative.

help the woman breathe into a paper bag. Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on her side will not solve this problem. Administration of a sedative could lead to neonatal depression since this woman, being in the transition phase, is near the birth process. The side-lying position would be appropriate for supine hypotension.

A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous (IV) infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: hydralazine. magnesium sulfate bolus. diazepam. calcium gluconate.

hydralazine. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is: severe after birth headache. limited perception of bladder fullness. increase in respiratory rate. hypotension.

hypotension. Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic because it would be with a low spinal (saddle block) anesthetic. Limited perception of bladder fullness is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.

A nurse providing care to a woman in labor should be aware that a clinical indication for a cesarean birth: is preference of the mother who may not want to go through the labor experience. is a shorter recovery time compared with vaginal deliveries. is performed primarily for the benefit of the fetus and/or mother in the context of clinical conditions. is an alternative birth method option if there is increased pain experienced by the mother during labor.

is performed primarily for the benefit of the fetus and/or mother in the context of clinical conditions. Clinical indication for a cesarean section is based on preventing complications that would impact either the fetus or the mother leading to adverse outcomes. Preference of the patient is not a clinical indication for this type of surgery. Recovery time is increased relative to vaginal delivery as a cesarean section is considered to be a major abdominal surgery. Increased pain is not a clinical indication for a cesarean section. Pain management can be implemented through various strategies including but not limited to nonpharmacologic and pharmacologic methods.

With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: the drugs can be given efficaciously up to the designated beginning of term at 37 weeks. there are no important maternal (as opposed to fetal) contraindications. its most important function is to afford the opportunity to administer antenatal glucocorticoids. if the client develops pulmonary edema while on tocolytics, intravenous (IV) fluids should be given.

its most important function is to afford the opportunity to administer antenatal glucocorticoids. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Administering intravenous fluids in the presence of pulmonary edema (regardless of origin) is contraindicated as it will lead to fluid overload.

After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: visceral. referred. somatic. afterpain.

referred. Visceral pain is that which predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early after birth period is uterine. This pain is very similar to that experienced in the first stage of labor.

A woman with severe preeclampsia is being treated with an intravenous (IV) infusion of magnesium sulfate. This treatment is considered successful if: blood pressure is reduced to prepregnant baseline. seizures do not occur. deep tendon reflexes become hypotonic. diuresis reduces fluid retention.

seizures do not occur. A temporary decrease in blood pressure can occur; however, this is not the purpose of administering this medication. Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration.

Nurses should be aware of the different experience can make in labor pain, such as: sensory pain for nulliparous women often is greater than for multiparous women during early labor. affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. women with a history of substance abuse experience more pain during labor. multiparous women have more fatigue from labor and therefore experience more pain.

sensory pain for nulliparous women often is greater than for multiparous women during early labor. Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

A woman is evaluated to be using an effective bearing-down effort if she: begins pushing as soon as she is told that her cervix is fully dilated and effaced. takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. uses the Valsalva maneuver by holding her breath and pushing vigorously for a count of 12. continues to push for short periods between uterine contractions throughout the second stage of labor.

takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. Bearing-down efforts should begin during the active-descent phase of the second stage of labor when the urge to bear down (Fresno reflex) is perceived. Cleansing breaths at the onset of a contraction allow it to build to a peak before pushing begins. They also enhance gas exchange in the alveoli and help the woman relax after the uterine contraction subsides. Women should avoid closed-glottis pushing (Valsalva maneuver) since uteroplacental perfusion is usually reduced. Open-glottis pushing is recommended. The woman should push with contractions to combine the force of both powers of labor: uterine and abdominal. Pushing gently between contractions is only advised when the fetal head is being delivered.

Concerning the third stage of labor, nurses should be aware that: the placenta eventually detaches itself from a flaccid uterus. the duration of the third stage may be as short as 3 to 5 minutes. it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. the major risk for women during the third stage is a rapid heart rate.

the duration of the third stage may be as short as 3 to 5 minutes. A. The placenta cannot detach itself from a flaccid (relaxed) uterus. B. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. C. Which surface of the placenta comes out first is not clinically important. D. The major risk for women during the third stage of labor is after birth hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

With regard to hemolytic diseases of the newborn, nurses should be aware that: Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. exchange transfusions frequently are required in the treatment of hemolytic disorders. the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth. Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility. An indirect Coombs' test may be performed on the mother a few times during pregnancy.