158 Quizzes

A nurse is caring for a client with an oxytocin infusion. What is the correct nursing action prior to increasing the oxytocin rate?

Monitor fetal heart tones.

A nurse in the birthing unit is caring for a client following an amniotomy. What is an appropriate nursing intervention?

Monitor temperature every 2 hours.

The nurse is assessing a client's risk for sexually transmitted infections. Which statement by the client would be cause for concern?

"I am unsure who the father of the baby is. I will be raising it alone."

Highly effective non-steroidal anti-inflammatory drug, given p.o., used to treat uterine cramping

Anaprox (Naproxen Sodium)

Narcotic that should not be given in transition

Nubain (Nalbuphine hydrochloride)

The nurse discusses various contraceptive methods with a client and her partner. Which method would the nurse explain as being available only with a prescription?

Diaphragm The diaphragm is available only by prescription and must be professionally fitted by a health care provider. Condoms and spermicides are available over the counter. Basal body temperature requires the use of a special thermometer that is available over the counter.

A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. The nurse's best response is

"Passage of the first stool within 48 hours is normal."

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?

"It varies, but you can estimate it returning in about 7 to 9 weeks." For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after childbirth.

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate?

"Your body is undergoing many changes that cause your bladder to fill quickly." Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum. Rapid bladder filling, possible infection, or effects of anesthesia are not involved.

A nurse is demonstrating the proper steps for breastfeeding a newborn to a client. Put these steps in the logical order that would assist the client in placing the newborn to her breast. 1. Tickle the newborn's lips with the nipple. 2. Bring the newborn to breast. 3. Newborn opens her mouth wide. 4. Have the newborn face the mother tummy to tummy. 5. Position the newborn so the newborn's nose is at level of the nipple.

(/5, 4, 1, 3, 2/)

The nurse is to administer naloxone (Narcan) intravenously. Which medication order would be the most appropriate initial dose to counteract a narcotic-induced maternal respiratory depression?

0.4-2.0 mg

The nurse is teaching a pregnant woman with a prepregnancy body mass index of 26 about recommended weight gain. The nurse determines that the teaching was successful when the woman states that she should gain approximately how much during pregnancy?

15 to 25 pounds (7 to 11 kilograms) A woman with a body mass index of 26 is considered overweight and should gain no more than 15 to 25 pounds (7 to 11 kilograms) during pregnancy. Women with a body mass index of 18.5 to 24.9 (considered healthy weight) should gain 25 to 35 pounds (11 to 16 kilograms). A woman with a body mass index less than 18.5 should gain 28 to 40 pounds (13 to 18 kilograms).

The nurse is reviewing client data following a regular monthly appointment at 6 months' gestation. Which fundal height requires no further intervention?

An anticipated fundal height for 24 weeks' gestation (6 months) is 24 cm. Between 18 and 32 weeks gestation, the fundal height in centimeters should match the gestational age. All of the other measurements would require further intervention.

The nurse is caring for a client who is scheduled for an induction at 8 a.m. The physician has ordered misoprostol (Cytotec) to be administered before the induction. In planning the client's care, the nurse should give the misoprostol (Cytotec) no later than:

4 a.m.

A nurse is caring for a client who received a spinal block for a cesarean birth. The client asks the nurse when she can get up to go to the nursery. The nurse's best response is: "You will need to remain in bed for at least __________."

6-12 hours

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9 a.m. If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?

A cephalhematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. The red blood cells present in the cephalhematoma begin to break down, which can lead to an increase in bilirubin levels in the blood.

A nurse is caring for a client during an amnioinfusion. Which fetal heart rate (FHR) pattern would be an expected outcome of a successful amnioinfusion?

A decrease in variable decelerations

A nurse is assessing a postpartum woman's adjustment to her maternal role. Which of the following would the nurse expect to occur first?

Assuming a passive role in meeting her own needs The first task of adjusting to the maternal role is the taking-in phase in which the mother demonstrates dependent behaviors and assumes a passive role in meeting her own basic needs. During the taking-hold phase, the mother becomes preoccupied with the present. During the letting-go phase, the mother reestablishes relationships with others and demonstrates increased responsibility and confidence in caring for the newborn.

A group of nursing students are reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as which of the following?

Attachment Attachment is a formation of a relationship between a parent and her/his newborn through a process of physical and emotional interactions. Puerperium refers to the postpartum period. Lactation refers to the process of milk secretion by the breasts. Engrossment refers to the bond that develops between the father and the newborn.

A nurse is preparing a class for a group of young adult women about emergency contraceptives (ECs). Which of the following would the nurse need to stress to the group. Select all that apply.

-ECs provide little protection for future pregnancies. -ECs are not to be used in place of regular birth control -ECs are birth control pills in higher, more frequent doses Important points to stress concerning ECs are that ECs do not offer any protection against STIs or future pregnancies; should not be used in place of regular birth control, as they are less effective; are regular birth control pills given at higher doses and more frequently; and are contraindicated during pregnancy (Miller, 2011). Contrary to popular belief, ECs do not induce abortion and are not related to mifepristone or RU-486, the so-called abortion pill approved by the FDA in 2000.

Needs to be taken with large glass of water

Colace (Docusate Sodium)

A nurse is preparing a class for a group of women at a family planning clinic about contraceptives. When describing the health benefits of oral contraceptives, which of the following would the nurse most likely include? (Select all that apply.)

-Protection against pelvic inflammatory disease -Reduced risk for endometrial cancer -Improvement in acne The health benefits of oral contraceptives include protection against pelvic inflammatory disease, a reduced risk for endometrial cancer, and improvement in acne. Oral contraceptives are associated with an increased risk for depression and migraine headaches.

Which of the following would lead the nurse to suspect that a postpartum woman is experiencing a problem?

Acute decrease in hematocrit Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output.

Butorphanol tartrate (Stadol) has been ordered for pain for a laboring client. What should the nurse's initial action be prior to administering the medication?

Assess for allergies.

The nurse is assisting a mother to feed her newborn. The newborn has been crying. The nurse suggests that prior to feeding, the mother should:

Burp the newborn

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal?

Chest circumference 31.5 cm, head circumference 33.5 cm The average circumference of the head at birth is 32—37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size.

The nurse interprets which of the following as evidence that a client is in the taking-in phase?

Client states, "He has my eyes and nose." During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.

Prostaglandin used to induce contractions and cause cervical ripening

Cytotec (Misoprostal)

Which of the following nursing interventions would protect the newborn immediately after birth from the most susceptible form of heat loss?

Drying the newborn thoroughly The most susceptible form of heat loss immediately after birth is evaporation. Evaporation occurs when water is converted to vapor. Drying the newborn thoroughly immediately after birth or after a bath will prevent heat loss by evaporation. Once the infant has been dried after birth, the highest losses of heat generally occur by radiation and convection.

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which of the following would the nurse identify as being least significant to this condition?

Early ambulation Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breast-feeding, and early ambulation.

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

Engagement The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn?

Eye prophylaxis medication

Which cardinal movement allows the fetus to travel through the birth canal most efficiently?

Flexion As the fetus progresses down the birth canal, flexion coaxes the fetus to assume the position of the smallest diameter of the fetal head to fit through the dimension of the pelvis. Extension and external rotation occurs later in the labor process before birth and passes the fetal head through the pubic arch to birth of the head. Engagement occurs when the fetal head descends to the level of the ischial spines and can occur 2 weeks prior to the initiation of labor.

A multigravida client is pregnant for the third time. Her previous two pregnancies ended in an abortion in the first and third month of pregnancy. How will the nurse classify her pregnancy history?

G3 P0020 Gravida (G) is the total number of pregnancies she has had, including the present one. Therefore she is G3 and not G2. Para (P), the outcome of her pregnancies, is further classified by the FPAL system as follows: F = Full term: number of babies born at 37 or more weeks of gestation, which is 0 and not 1 in this case. P = Preterm: number of babies born between 20 and 37 weeks of gestation, which is 0 in this case. A = Abortions: total number of spontaneous and elective abortions, which is 2 in this case. L = Living children, as of today. She has no living children; therefore, it is 0 and not 1.

A client has been confirmed to be pregnant. She gives a history of two previous full-term normal pregnancies. How will the nurse classify the client's pregnancy history?

G3, P2 Gravida (G) is the total number of pregnancies the client has had, including the present one, and para (P) is the number of babies born at 20 or more weeks of gestation. Since she gives a history of two previous normal deliveries, she is P2 and not P0, P1, or P3. Because she has had a total of three pregnancies including the present one, she is G3 and not G2.

The nurse is caring for four laboring clients. Which client would be the most appropriate candidate for an epidural block?

G5P4 dilated 7-8 cm

Which client would most likely be induced with a prostaglandin agent? A woman with: (Select all that apply.)

Gestational diabetes. Postdate pregnancy.

When discussing contraceptive options, which method would the nurse recommend as being the most reliable?

Intrauterine system An intrauterine system is the most reliable method because users have to consciously discontinue using them to become pregnant rather than making a proactive decision to avoid conception. Coitus interruptus, LAM, and natural family planning are behavioral methods of contraception and require active participation of the couple to prevent pregnancy. These behavioral methods must be followed exactly as prescribed.

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

Less than after a vaginal delivery Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

Sometimes given postpartum for excessive bleeding. Side effect severe uterine cramping

Methergine (Methylergonavine maleate)

A nurse is evaluating the diet plan of a breastfeeding mother. Which of the following drinks is most likely to cause an intolerance for the infant?

Milk Generally, mothers can continue to eat and drink everything they are accustomed to while breastfeeding. There are rare instances in which some infants are intolerant to something in the mother's milk. The most common problems come from dairy products. The mother should be referred to a lactation consultant if this occurs

Which of the following newborn characteristics affect the establishment of a neutral thermal environment in the newborn? Select all that apply.

Newborns have a decrease in subcutaneous fat. Blood vessels are closer to the skin. Flexed posture of the term newborn

A woman reports that her LMP occurred on January 10, 2017. Using Naegele rule, what is her due date?

October 17, 2017 To determine the due date using Naegele rule, add seven days to the date of the first day of the LMP, then subtract three months.

A woman has opted to use the basal body temperature method for contraception. The nurse instructs the client that a rise in basal body temperature indicates which of the following?

Ovulation Basal body temperatures typically rise within a day or two after ovulation and remain elevated for approximately 2 weeks, at which point bleeding usually begins. Basal body temperature is not a means for determining pregnancy. Having intercourse while the temperature is elevated would increase the risk of pregnancy.

A group of students are reviewing the process of breast milk production. The students demonstrate understanding when they identify which hormone as responsible for milk let-down?

Oxytocin Oxytocin is released from the posterior pituitary to promote milk let-down. Prolactin levels increase at term with a decrease in estrogen and progesterone; estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production.

The nurse is caring for a newborn 30 minutes after birth. During an assessment of respiratory function, the following data are collected. Which of the following assessment findings would the nurse report as abnormal? Select all that apply.

Periodic breathing with pauses of 25 seconds Grunting on expiration Nasal flaring Periodic breathing should last no more than 15 seconds. Expiratory grunting is a sign of Respiratory Distress Syndrome. Nasal flaring is a sign of Respiratory Distress Syndrome.

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which of the following would the nurse expect to find?

Pinkish brown discharge Lochia serosa is pinkish brown and is expelled 3 to 10 days postpartum. Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. Lochia alba is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content and occurs from days 10 to 14 but can last 3 to 6 weeks postpartum.

The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing intervention would be appropriate?

Placing a gloved finger in the newborn's mouth

Which of the following nursing interventions would protect the newborn from heat loss by convection?

Placing the newborn away from air currents

A nurse is preparing a prenatal client with a breech presentation for an external cephalic version (ECV). What condition must be met prior to this procedure?

Reactive nonstress test

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus, expecting it to be at which location?

Two fingerbreadths below the umbilicus During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.

The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets this as indicating which of the following stages?

Reality The partner's statement reflects stage 2 (reality), which occurs when fathers or partners realize that their expectations in stage 1 are not realistic. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn's care and yet do not feel prepared to do so. New fathers or partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Many men may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. In stage 3 (transition to mastery), the father or partner makes a conscious decision to take control and be at the center of his newborn's life regardless of his preparedness. Taking-hold is a stage of maternal adaptation. The partner's statement reflects stage 2 (reality), which occurs when fathers or partners realize that their expectations in stage 1 are not realistic. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn's care and yet do not feel prepared to do so. New fathers or partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Many men may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. In stage 3 (transition to mastery), the father or partner makes a conscious decision to take control and be at the center of his newborn's life regardless of his preparedness. Taking-hold is a stage of maternal adaptation.

A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person, and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears, the nurse should mention the role of the hormone that softens the cervix and collagen in the joints, which allows dilation and enlargement of the birth canal. What is this hormone?

Relaxin Relaxin, secreted by the corpus luteum of the ovary as well as the placenta, is responsible for helping to inhibit uterine activity and to soften the cervix and the collagen in joints. Softening of the cervix allows for dilatation at birth; softening of collagen allows for laxness in the lower spine and so helps enlarge the birth canal. The effect of estrogen is to cause breast and uterine enlargement. Progesterone has a major role in maintaining the endometrium, inhibiting uterine contractility, and aiding in the development of the breasts for lactation. Human placental lactogen (hPL), also known as human chorionic somatomammotropin, serves as an antagonist to insulin, making insulin less effective, thereby allowing more glucose to become available for fetal growth.

A woman using the cervical mucus ovulation method of fertility awareness reports that her cervical mucus looks like egg whites. The nurse interprets this as which of the following?

Spinnbarkeit mucus The client is describing spinnbarkeit mucus, the copious, clear, slippery, smooth, and stretchable mucus that occurs as ovulation approaches. Purulent mucus would be yellow or green and malodorous. Preovulation mucus is clear but not as copious, slippery, and stretchable.

A client is to receive an implantable contraceptive. The nurse describes this contraceptive as containing:

Synthetic progestin Implantable contraceptives deliver synthetic progestin that acts by inhibiting ovulation and thickening cervical mucus so sperm cannot penetrate. Implantable contraceptives do not contain combined estrogen and progestin, concentrated spermicide, or concentrated estrogen.

During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as:

Telangiectatic nevi (stork bites) are pale pink or red spots that appear on the eyelids, nose, lower occipital bone, or the nape of the neck.

The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses:

The clavicle

A mother is concerned because the anterior fontanelle swells when the newborn cries. What would the nurse include in her teaching to a new mother about the normal findings concerning the fontanelles? Select all that apply.

The fontanelles can swell with crying. The fontanelles can swell when stool is passed. The fontanelles can pulsate with the heartbeat.

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalhematoma. Which of the following characteristics would indicate a cephalhematoma? Select all that apply.

The mass appears only on one side of the head. The mass appeared on the second day after birth.

A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers?

The newborn's cry

The nurse has assessed four newborns' respiratory rates immediately following birth. Which of the following respiratory rates would require further assessment by the nurse?

The normal range for respirations of a newborn within 2 hours after birth is 60—70 breaths per minute. If respirations drop below 30 breaths per minute when the infant is at rest, the nurse should notify the physician.

At birth, an infant weighed 6 pounds, 12 ounces. Three days later, he weighs 5 pounds, 2 ounces. What conclusion should the nurse draw regarding this newborn's weight?

Weight loss is excessive This newborn has lost more than 10% of the birth weight, so this newborn's weight loss is excessive. During the first 5—10 days of life, caloric intake often is insufficient for weight gain. Therefore, there can be a weight loss of 5—10% in term newborns.

A postpartum client calls the clinic to report that her 3-day-old baby girl has a spot of blood on her diaper. The nurse explains to the client that this is due to:

Withdrawal of maternal hormones. As maternal hormones clear the newborn, it is not unusual to find blood on the diapers of a female newborn. This is referred to as pseudomenstruation.

A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible?

Women should be able to move about freely throughout labor. Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced; 2) women should be able to move about freely throughout labor, not be confined to bed; 3) women should receive continuous support from a caring other during labor; 4) no interventions such as intravenous fluid should be used routinely; 5) women should be allowed to assume a nonsupine position such as upright and side-lying for birth; and 6) mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding.

A nurse is making a home visit to the parents of a newborn. This is their first baby. During the visit, the nurse observes the parents interacting with their newborn and notes that they demonstrate responsible behaviors to promote the infant's growth and development. The nurse interprets this behavior as reflecting:

centrality. Centrality, which is a component of commitment, is demonstrated when the parents place the infant at the center of their lives, acknowledging and accepting their responsibility to promote the infant's safety, growth and development. Contact, a dimension of proximity, refers to the sensory experiences of touching, holding, and gazing at the infant. Individualization, a dimension of proximity, reflects parental awareness of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately. Reciprocity is the process by which the infant's abilities and behaviors elicit a parental response.

A nurse is teaching a group of nursing students about the mechanism of labor when the fetus is in a cephalic presentation. The nurse determines the session is successful when the students correctly place the following events in which order? All options must be used.

flexion internal rotation extension external rotation expulsion The sequence of normal mechanism of labor involves descent, flexion, internal rotation, extension, external rotation, and expulsion. Following descent, the baby's head encounters resistance and flexes so that the chin touches the chest. During internal rotation, the occiput is rotated 45° anteriorly so as to lie beneath the symphysis pubis. The baby's neck is twisted in internal rotation. Following internal rotation, the delivery of the head is by extension. Once the head is born by extension, there is external rotation, in which it turns 45° more so that the shoulders lie anterior posteriorly.

A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating:

hemodilution of pregnancy. During pregnancy, the red blood cell count increases along with an increase in plasma volume. However, there is a greater increase in the plasma volume as a result of hormonal factors and sodium and water retention. Thus, the plasma increase exceeds the increase in RBCs, resulting in hemodilution of pregnancy, which is also called physiologic anemia of pregnancy. Changes in maternal iron levels would be more indicative of an iron-deficiency anemia. Although anemia may be present with a multiple gestation, an ultrasound would be a more reliable method of identifying it. Weight gain does not correlate with hemoglobin levels.

A new family decides not to have their newborn circumcised. What should the nurse teach regarding uncircumcised care?

Avoid retracting foreskin The foreskin is not fully retractable until around the age of 3—5 years.

The nurse is advising a pregnant woman during her first prenatal visit regarding the frequency of future visits. Which schedule is recommended for prenatal care?

once every 4 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth The best health for mother and baby results when the mother has her first visit before the end of the first trimester (before the end of week 13) and then has regular visits until after she has delivered the baby. The usual timing for visits is about once every 4 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth.

The nurse is providing education regarding fetal kicks/movement to a 22 weeks primigravid in the family planning clinic. Which client statement indicates an understanding of the teaching?

"I will document fetal kicks/movement daily and they should be 10 every 2 hours." A healthy fetus moves and kicks regularly. Instruction to the first time mother includes onset of feeling the fetal kicks (16 to 20 weeks gestation) and understanding typical kick counts (10 kicks per 2 hours). Clients are encouraged to document each kick or change in position on a piece of paper. It is unrealistic to think the mother will record fetal movement and kicks each hour. Checking the kicks and movement should be completed daily not weekly.

A mother of a 16-week-old infant calls the clinic, and is concerned because she cannot feel the posterior fontanelle on her infant. Which of the responses by the nurse would be most appropriate?

"It is normal for the posterior fontanelle to close by 8—12 weeks after birth."

A routine hematocrit level is drawn on a newborn immediately after delivery and is found to be 68%. What might have contributed to this abnormally high hematocrit level?

Delayed Cord Clamping Blood volume increases by approximately 61% with delayed cord clamping; The increase is reflected by a rise in hemoglobin level and an increase in the hematocrit.

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as which of the following?

Engorgement Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn.

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

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

A nursing student is preparing a class presentation about changes in the various body systems during the postpartum period and their effects. Which of the following would the student include as influencing a postpartum woman's ability to void? (Select all that apply.)

Generalized swelling of the perineum Decreased bladder tone from regional anesthesia Use of oxytocin to augment labor Many women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment their labor (antidiuretic effect). These women will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. In addition, urination may be impeded by perineal lacerations; generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus; hematomas; decreased bladder tone as a result of regional anesthesia; and diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor.

The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: TSH slightly elevated, glucose in the urine, complete blood count low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition?

Gestational diabetes Glycosuria, glucose in the urine, may occur normally during pregnancy, however if it appears in the urine, the patient should be sent for test to rule out gestational diabetes. Preeclampsia, anemia, and hypothyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hyperthyroidism instead of hypothyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.

Which nursing action is a priority when the fetus is at the +4 station?

Have a blue bulb suction and an infant warmer ready At the station +4, the fetus is being born. The priority nursing action is to have a blue bulb or suction device for airway clearance and an infant warmer ready. During admission the nurse will place a tocometer on the maternal stomach and have a gown ready. For checking effacement and dilation, the nurse will have a lubricant and possibly an internal monitor per health care provider orders. A cesarean section is not needed as the fetus has progressed through the birth canal.

A nurse is instructing the nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply

Inject in the vastus lateralis muscle. Gently massage the site after injection. Cleanse site with alcohol prior to injection.

A nurse is caring for a preoperative cesarean birth client. The surgery is scheduled, and is not an emergency. The patient has never been hospitalized, has never had surgery, and is very anxious. In planning care, which nursing action takes top priority?

Sit and talk with the patient.

A telephone triage nurse gets a call from a postpartum client concerned about jaundice. The client's newborn is 37 hours old. What data would the nurse need to gather first?

Skin color

A nurse is reviewing the charts of four clients in the birthing unit. Which client has an increased risk for an episiotomy?

The client laboring in a lithotomy position

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor?

placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/dL. Precipitous labor, less than 3 hours, and multiparity, more than three births closely spaced, place a woman at risk for postpartum hemorrhage.

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in?

taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the puerperium.