Chapter 13 Quiz

A nurse is assisting in the resuscitation of a newborn. The nurse would expect to stop resuscitation efforts when the newborn has no heartbeat and respiratory effort after which time frame? A. 20 minutes B. 10 minutes C. 15 minutes D. 5 minutes

A. 20 minutes CorrectB. 10 minutes C. 15 minutes D. 5 minutes According to the American Heart Association and American Academy of Pediatrics Guidelines for Neonatal Resuscitation, resuscitation efforts may be stopped if the newborn exhibits no heartbeat and no respiratory effort after 10 minutes of continuous and adequate resuscitation. Chapter Number: 24

After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension? A. Client has a twin sister. B. Sister-in-law had gestational hypertension. C. Mother had gestational hypertension during pregnancy. D. This is the client's second pregnancy.

A. Client has a twin sister. B. Sister-in-law had gestational hypertension. CorrectC. Mother had gestational hypertension during pregnancy. D. This is the client's second pregnancy. Rationale: A family history of gestational hypertension, such as a mother or sister, is considered a risk factor for the client. Having a twin sister or having a sister-in-law with gestational hypertension would not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy, then she would be at risk in her second pregnancy. Chapter 19

A group of nurses are reviewing information about mastitis and its causes in an effort to develop a teaching program on prevention for postpartum women. The nurses demonstrate understanding of the information when they focus the teaching on ways to minimize risk of exposure to which organism? A. E. coli B. Klebsiella C. S. aureus D. Proteus

A. E. coli B. Klebsiella CorrectC. S. aureus D. Proteus The most common infectious organism that causes mastitis is S. aureus, which comes from the breast-feeding infant's mouth or throat. E. coli is another, less common cause. E. coli, Proteus, and Klebsiella are common causes of urinary tract infections. Chapter Number: 22

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care? A. administration of labetalol B. total parenteral nutrition C. clear liquid diet D. nothing by mouth

A. administration of labetalol B. total parenteral nutrition C. clear liquid diet CorrectD. nothing by mouth Typically, on admission, the woman with hyperemesis has oral food and fluids withheld to rest the gut and receives parenteral fluids to rehydrate and reduce the symptoms. Once the condition stabilizes, oral intake is gradually increased. Total parenteral nutrition may be used if the client's condition does not improve with several days of bed rest, gut rest, IV fluids, and antiemetics. Labetalol is an antihypertensive agent that may be used to treat gestational hypertension, not hyperemesis. Chapter Number: 19

A woman with a history of asthma comes to the clinic for evaluation for pregnancy. The woman's pregnancy test is positive. When reviewing the woman's medication therapy regimen for asthma, which medication would the nurse identify as problematic for the woman now that she is pregnant? A. budesonide B. oral prednisone C. albuterol D. salmeterol

A. budesonide CorrectB. oral prednisone C. albuterol D. salmeterol Rationale: Oral corticosteroids such as prednisone are not preferred for the long-term treatment of asthma during pregnancy. However, they can be used to treat severe asthma attacks during pregnancy. Budesonide, albuterol, and salmeterol are recommended for use during pregnancy to control asthma. Chapter 20

A nurse is reviewing the maternal history of an LGA newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn? A. drug abuse B. preeclampsia C. diabetes D. infection

A. drug abuse B. preeclampsia CorrectC. diabetes D. infection Rationale: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdates gestation, maternal obesity, male fetus, and genetics. Drug abuse is associated with SGA newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth. Chapter 23

Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia? A. ferrous sulfate B. calcium gluconate C. potassium chloride D. calcium carbonate

A. ferrous sulfate CorrectB. calcium gluconate C. potassium chloride D. calcium carbonate Response Feedback: The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity. Chapter Number: 19 Page: 677

A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate intervention? A. fetal heart rate of 150 beats/minute B. uterine resting tone of 14 mm Hg C. urine output of 20 mL/hour D. contractions every 2 minutes, lasting 45 seconds

A. fetal heart rate of 150 beats/minute B. uterine resting tone of 14 mm Hg CorrectC. urine output of 20 mL/hour D. contractions every 2 minutes, lasting 45 seconds Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150 beats/minute is within the accepted range of 120 to 160 beats/minutes. Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20 mm Hg would require intervention. Chapter Number: 21

A newborn is suspected of having fetal alcohol syndrome. Which finding would the nurse expect to assess? A. hydrocephaly B. flattened maxilla C. hypoactivity D. bradypnea

A. hydrocephaly CorrectB. flattened maxilla C. hypoactivity D. bradypnea Rationale: A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity. Chapter 24

The nurse is providing care to a newborn with severe meconium aspiration syndrome (MAS). The nurse is reviewing the newborn's diagnostic test results. Which finding would the nurse expect? A. increased PaO2 B. vocal cords negative for meconium C. elevated blood pH D. patchy fluffy infiltrates on chest X-ray

A. increased PaO2 B. vocal cords negative for meconium C. elevated blood pH CorrectD. patchy fluffy infiltrates on chest X-ray Rationale: Chest X-rays show patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaeration mixed with areas of atelectasis. ABG analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2.Direct visualization of the vocal cords for meconium staining using an appropriate size laryngoscope is needed. Chapter 24

A newborn has an Apgar score of 6 at 5 minutes. Which action would be the priority? A. initiating IV fluid therapy B. obtaining a blood culture C. beginning resuscitative measures D. promoting kangaroo care

A. initiating IV fluid therapy B. obtaining a blood culture CorrectC. beginning resuscitative measures D. promoting kangaroo care Rationale: An Apgar score below 7 at 1 or 5 minutes indicates the need for resuscitation. Intravenous fluid therapy and blood cultures may be done once resuscitation is started. Kangaroo care would be appropriate once the newborn is stable. Chapter 24

A nurse suspects that a pregnant client may be experiencing abruptio placenta based on assessment of which finding? Select all that apply. A. insidious onset B. rigid uterus C. dark red vaginal bleeding D. absent fetal heart tones E. absence of pain

A. insidious onset CorrectB. rigid uterus CorrectC. dark red vaginal bleeding CorrectD. absent fetal heart tones E. absence of pain Assessment findings associated with abruptio placenta include a sudden onset, with concealed or visible bleeding, dark red bleeding, constant pain or uterine tenderness on palpation, firm to rigid uterine tone, and fetal distress or absent fetal heart tones. Chapter Number: 19

A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? A. manually removing the placenta at delivery B. inspecting the placenta after delivery for intactness C. applying pressure to the umbilical cord to remove the placenta D. administering broad-spectrum antibiotics

A. manually removing the placenta at delivery CorrectB. inspecting the placenta after delivery for intactness C. applying pressure to the umbilical cord to remove the placenta D. administering broad-spectrum antibiotics After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage. Chapter Number: 22

A postpartum client is prescribed medication therapy as part of the treatment plan for postpartum hemorrhage. Which medication would the nurse least expect to administer in this situation? A. methylergonovine B. carboprost C. nifedipine D. oxytocin

A. methylergonovine B. carboprost CorrectC. nifedipine D. oxytocin Rationale: Nifedipine inhibits uterine activity to arrest preterm labor. It would not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage. Chapter 22

When preparing a schedule of follow-up visits for a pregnant woman with chronic hypertension, which schedule would be most appropriate? A. monthly visits until 20 weeks, then bi-monthly visits B. monthly visits until 32 weeks, then bi-monthly visits C. bi-monthly visits until 36 weeks, then weekly visits D. bi-monthly visits until 28 weeks, then weekly visits

A. monthly visits until 20 weeks, then bi-monthly visits B. monthly visits until 32 weeks, then bi-monthly visits C. bi-monthly visits until 36 weeks, then weekly visits CorrectD. bi-monthly visits until 28 weeks, then weekly visits Rationale: For the woman with chronic hypertension, antepartum visits typically occur every 2 weeks until 28 weeks' gestation and then weekly to allow for frequent maternal and fetal surveillance. Chapter 20

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? A. more subcutaneous fat in the neck and abdomen B. fewer visible blood vessels through the skin C. well-developed flexor muscles in the extremities D. greater surface area in proportion to weight

A. more subcutaneous fat in the neck and abdomen B. fewer visible blood vessels through the skin C. well-developed flexor muscles in the extremities CorrectD. greater surface area in proportion to weight Rationale: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone. Chapter 23

A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding? A. nonpalpable fundus B. moderate lochia serosa C. fever D. bruising on arms and legs

A. nonpalpable fundus CorrectB. moderate lochia serosa C. fever D. bruising on arms and legs Response Feedback: Subinvolution is usually identified at the woman's postpartum examination 4 to 6 weeks after birth. The clinical picture includes a postpartum fundal height that is higher than expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within a few weeks. Normally, at 4 to 6 weeks, lochia alba or no lochia would be present and the fundus would not be palpable. Thus evidence of lochia serosa suggests subinvolution. Bruising would suggest a coagulopathy. Fever would suggest an infection. Chapter Number: 22 Page: 801

The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which area because of the woman's increased risk? A. post-term labor B. preeclampsia C. oligohydramnios D. chorioamnionitis

A. post-term labor CorrectB. preeclampsia C. oligohydramnios D. chorioamnionitis Rationale: Women with multiple gestations are at high risk for preeclampsia, preterm labor, hydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis. Chapter 19

A nurse is reviewing the maternal history of an LGA newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn? A. preeclampsia B. diabetes C. drug abuse D. infection

A. preeclampsia CorrectB. diabetes C. drug abuse D. infection Response Feedback: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdates gestation, maternal obesity, male fetus, and genetics. Drug abuse is associated with SGA newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth. Chapter Number: 23 Page: 840

A home health care nurse is assessing a postpartum woman who was discharged 2 days ago. The woman tells the nurse that she has a low-grade fever and feels "lousy." Which finding would lead the nurse to suspect metritis? Select all that apply. A. urgency B. anorexia C. flank pain D. lower abdominal tenderness E. breast tenderness

A. urgency CorrectB. anorexia C. flank pain CorrectD. lower abdominal tenderness E. breast tenderness Rationale: Manifestations of metritis include lower abdominal tenderness or pain on one or both sides, elevated temperature, foul-smelling lochia, anorexia, nausea, fatigue and lethargy, leukocytosis, and elevated sedimentation rate. Urgency and flank pain would suggest a urinary tract infection. Breast tenderness may be related to engorgement or suggest mastitis. Chapter 22

A pregnant woman tests positive for HBV. What would the nurse expect to administer? A. acylcovir B. HBV immune globulin C. valacyclovir D. HBV vaccine

CORRECT = B) HBV immune globulin Rationale: If a woman tests positive for HBV, expect to administer HBV immune globulin. The newborn will also receive HBV vaccine within 12 hours of birth. Acyclovir or valacyclovir would be used to treat herpes simplex virus infection. Chapter 20

A pregnant woman asks the nurse, "I'm a big coffee drinker. Will the caffeine in my coffee hurt my baby?" Which response by the nurse would be most appropriate? A. "The caffeine in coffee has been linked to birth defects." B. "Caffeine is a stimulant and needs to be avoided completely." C. "If you keep your intake to less than 300 mg/day, you should be okay." D. "Caffeine has been shown to cause growth restriction in the fetus.

CORRECT = C) "If you keep your intake to less than 300 mg/day, you should be okay." Rationale: The effect of caffeine intake during pregnancy on fetal growth and development is still unclear. However, a recent study showed that moderate caffeine consumption (less than 300 mg per day) does not appear to be a major contributing factor in miscarriage or preterm birth. The relationship of caffeine to growth restriction remains undetermined. A final conclusion cannot be made at this time as to whether there is a correlation between high caffeine intake and miscarriage due to lack of sufficient studies. Birth defects have not been linked to caffeine consumption. Chapter 20

A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding? (chapter 19)

Correct- A. elevated liver enzymes B. elevated platelet count C. hyperglycemia D. disseminated intravascular coagulopathy (DIC)

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A. alert level of consciousness B. diminished deep tendon reflexes C. urine output of 45 mL/hour D. respiratory rate of 16 breaths per minute

Correct: B. diminished deep tendon reflexes Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness. Chapter Number: 21

A pregnant woman at 31-weeks' gestation calls the clinic and tells the nurse that she is having contractions sporadically. Which instructions would be most appropriate for the nurse to give the woman? Select all that apply. A. "Try emptying your bladder." B. "Walk around the house for the next half hour." C. "Stop what you are doing and rest." D. "Drink 2 or 3 glasses of water." E. "Lie down on your back."

CorrectA. "Try emptying your bladder." B. "Walk around the house for the next half hour." CorrectC. "Stop what you are doing and rest." CorrectD. "Drink 2 or 3 glasses of water." E. "Lie down on your back." Rationale: Appropriate instructions for the woman who may be experiencing preterm labor include having the client stop what she is doing and rest for an hour, empty her bladder, lie down on her left side, and drink two to three glasses of water." Chapter 21

A nurse is providing a refresher class for a group of postpartum nurses. The nurse reviews the risk factors associated with postpartum hemorrhage. The group demonstrates understanding of the information when they identify which risk factors associated with uterine tone? Select all that apply. A. rapid labor B. retained blood clots C. hydramnios D. operative birth E. fetal malpostion

CorrectA. rapid labor B. retained blood clots CorrectC. hydramnios D. operative birth E. fetal malpostion Rationale: Risk factors associated with uterine tone include hydramnios, rapid or prolonged labor, oxytocin use, maternal fever, or prolonged rupture of membranes. Retained blood clots are a risk factor associated with tissue retained in the uterus. Fetal malposition and operative birth are risk factors associated with trauma of the genital tract. Chapter 22

A nurse is assessing a post-term newborn. Which finding would the nurse correlate with this gestational age variation? A. thin umbilical cord B. absence of sole creases C. abundant lanugo and vernix D. moist, supple, plum skin appearance

CorrectA. thin umbilical cord B. absence of sole creases C. abundant lanugo and vernix D. moist, supple, plum skin appearance Rationale: A post-term newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet. Chapter 23

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A. "How do you feel about delivering your baby at 36 weeks?" B. "You are lucky to have given birth to a term newborn." C. "We still need to monitor him closely for problems." D. "Your baby is premature and needs monitoring in the NICU."

A. "How do you feel about delivering your baby at 36 weeks?" B. "You are lucky to have given birth to a term newborn." CorrectC. "We still need to monitor him closely for problems." D. "Your baby is premature and needs monitoring in the NICU." Rationale: A baby born at 36 weeks' gestation is considered a late preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the delivery demonstrates caring but does not address the woman's lack of understanding about her newborn. Chapter 23

A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? A. "I keep hearing voices telling me to take my baby to the river." B. "I'm feeling so guilty and worthless lately." C. "It's strange, one minute I'm happy, the next I'm sad." D. "I just feel so overwhelmed and tired.

A. "I keep hearing voices telling me to take my baby to the river." CorrectB. "I'm feeling so guilty and worthless lately." C. "It's strange, one minute I'm happy, the next I'm sad." D. "I just feel so overwhelmed and tired. rationale: Indicators for postpartum depression include feelings related to restlessness, worthlessness, guilt, hopeless, and sadness along with loss of enjoyment, low energy level, and loss of libido. The statements about being overwhelmed and fatigued and changing moods suggest postpartum blues. The statement about hearing voices suggests postpartum psychosis. Chapter 22

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate? A. "I know to call my health care provider right away if I start to bleed again." B. "My mother lives next door and can drive me here if necessary." C. "I have a toddler and preschooler at home who need my attention." D. "I realize the importance of following the instructions for my care."

A. "I know to call my health care provider right away if I start to bleed again." B. "My mother lives next door and can drive me here if necessary." CorrectC. "I have a toddler and preschooler at home who need my attention." D. "I realize the importance of following the instructions for my care." Rationale: Having a toddler and preschooler at home needing attention suggest that the woman would have difficulty maintaining bed rest at home. Therefore, expectant management at home may not be appropriate. Expectant management is appropriate if the mother and fetus are both stable, there is no active bleeding, the client has readily available access to reliable transportation, and can comprehend instructions. Chapter 19

A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement? A. "I need to avoid drinking any alcohol." B. "I can take ibuprofen if I have any pain." C. "I will use a soft toothbrush to brush my teeth." D. "I will call my health care provider if my stools are black and tarry."

A. "I need to avoid drinking any alcohol." CorrectB. "I can take ibuprofen if I have any pain." C. "I will use a soft toothbrush to brush my teeth." D. "I will call my health care provider if my stools are black and tarry." Rationale: Individuals receiving anticoagulant therapy need to avoid use of any over-the-counter products containing aspirin or aspirin-like derivatives such as NSAIDs (ibuprofen) to reduce the risk for bleeding. Using a soft toothbrush and avoiding alcohol are appropriate measures to reduce the risk for bleeding. Black, tarry stools should be reported to the health care provider. Chapter 22

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate? A. "I realize the importance of following the instructions for my care." B. "My mother lives next door and can drive me here if necessary." C. "I know to call my health care provider right away if I start to bleed again." D. "I have a toddler and preschooler at home who need my attention."

A. "I realize the importance of following the instructions for my care." B. "My mother lives next door and can drive me here if necessary." C. "I know to call my health care provider right away if I start to bleed again." CorrectD. "I have a toddler and preschooler at home who need my attention." Having a toddler and preschooler at home needing attention suggest that the woman would have difficulty maintaining bed rest at home. Therefore, expectant management at home may not be appropriate. Expectant management is appropriate if the mother and fetus are both stable, there is no active bleeding, the client has readily available access to reliable transportation, and can comprehend instructions. Chapter Number: 19

After teaching a pregnant woman with iron deficiency anemia about her prescribed iron supplement, which statement indicates successful teaching? A. "I should avoid drinking orange juice." B. "I should take my iron with milk." C. "I need to eat foods high in fiber." D. "I'll call the primary care provider if my stool is black and tarry."

A. "I should avoid drinking orange juice." B. "I should take my iron with milk." CorrectC. "I need to eat foods high in fiber." D. "I'll call the primary care provider if my stool is black and tarry." Rationale: Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin C-containing fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her primary care provider. Chapter 20

The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful? A. "I'll adjust my diet and insulin based on the results of my urine tests for glucose." B. "Because I need extra protein, I'll have to increase my intake of milk and meat." C. "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D. "I'll basically follow the same diet that I was following before I became pregnant."

A. "I'll adjust my diet and insulin based on the results of my urine tests for glucose." B. "Because I need extra protein, I'll have to increase my intake of milk and meat." CorrectC. "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D. "I'll basically follow the same diet that I was following before I became pregnant." Rationale: In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy. Chapter 20

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? A. "I'll be here to help you all along the way." B. "Let me tell you about what you will see when you visit your baby." C. "What has helped you to deal with stressful situations in the past?" D. "Forget about what's happened in the past, and focus on the now."

A. "I'll be here to help you all along the way." B. "Let me tell you about what you will see when you visit your baby." C. "What has helped you to deal with stressful situations in the past?" CorrectD. "Forget about what's happened in the past, and focus on the now." Instead of telling the parents to forget about what has happened, the nurse should review with them the events that have occurred since birth to help them understand and clarify any misconceptions they might have. Other helpful interventions would include telling the parents that the nurse will be with them because this provides them with a physical presence and support; asking about previous coping strategies that worked so that they can use them now; and explaining what is happening and all the equipment being used so they can understand the situation. Chapter Number: 23

After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? A. "I'll point the spray of the peri-bottle so it the water flows front to back." B. "When I put on a new pad, I'll start at the back and go forward." C. "If I have chills or my discharge has a strange odor, I'll call my doctor." D. "I need to call my doctor if my temperature goes above 100.4° F (38° C)."

A. "I'll point the spray of the peri-bottle so it the water flows front to back." CorrectB. "When I put on a new pad, I'll start at the back and go forward." C. "If I have chills or my discharge has a strange odor, I'll call my doctor." D. "I need to call my doctor if my temperature goes above 100.4° F (38° C)." Response Feedback: The woman needs additional teaching when she states that she should apply the perineal pad starting at the back and going forward. The pad should be applied using a front-to-back motion. Notifying the health care provider of a temperature above 100.4° F (38° C), aiming the peri-bottle spray so that the flow goes from front to back, and reporting danger signs such as chills or lochia with a strange odor indicate effective teaching. Chapter Number: 22 Page: 817

After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A. "I'll probably have a tube in my bladder for about 24 hours or so." B. "I guess the nurses will be getting me up and out of bed rather quickly." CorrectC. "I'm going to have to wait a few days before I can start breast-feeding." D. "Holding a pillow against my incision will help me when I cough."

A. "I'll probably have a tube in my bladder for about 24 hours or so." B. "I guess the nurses will be getting me up and out of bed rather quickly." CorrectC. "I'm going to have to wait a few days before I can start breast-feeding." D. "Holding a pillow against my incision will help me when I cough." Typically, breast-feeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours. Chapter Number: 21

A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman makes which statement? A. "I'll try to move my bowels." B. "I'll drink several glasses of water." C. "I'll lie down with my legs raised." D. "I'll sit down to rest for 30 minutes."

A. "I'll try to move my bowels." CorrectB. "I'll drink several glasses of water." C. "I'll lie down with my legs raised." D. "I'll sit down to rest for 30 minutes." Response Feedback: If the woman experiences any signs and symptoms of preterm labor, she should stop what she is doing and rest for 1 hour, empty her bladder, lie down on her side, drink two to three glasses of water, feel her abdomen and note the hardness of the contraction, and call her health care provider and describe the contraction. Chapter Number: 21 Page: 774

After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? A. "If I have chills or my discharge has a strange odor, I'll call my doctor." B. "I need to call my doctor if my temperature goes above 100.4° F (38° C)." C. "I'll point the spray of the peri-bottle so it the water flows front to back." D. "When I put on a new pad, I'll start at the back and go forward."

A. "If I have chills or my discharge has a strange odor, I'll call my doctor." B. "I need to call my doctor if my temperature goes above 100.4° F (38° C)." C. "I'll point the spray of the peri-bottle so it the water flows front to back." CorrectD. "When I put on a new pad, I'll start at the back and go forward." The woman needs additional teaching when she states that she should apply the perineal pad starting at the back and going forward. The pad should be applied using a front-to-back motion. Notifying the health care provider of a temperature above 100.4° F (38° C), aiming the peri-bottle spray so that the flow goes from front to back, and reporting danger signs such as chills or lochia with a strange odor indicate effective teaching. Chapter Number: 22

After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? A. "If I have chills or my discharge has a strange odor, I'll call my doctor." B. "I need to call my doctor if my temperature goes above 100.4° F (38° C)." C. "When I put on a new pad, I'll start at the back and go forward." D. "I'll point the spray of the peri-bottle so it the water flows front to back."

A. "If I have chills or my discharge has a strange odor, I'll call my doctor." B. "I need to call my doctor if my temperature goes above 100.4° F (38° C)." CorrectC. "When I put on a new pad, I'll start at the back and go forward." D. "I'll point the spray of the peri-bottle so it the water flows front to back." Response Feedback: The woman needs additional teaching when she states that she should apply the perineal pad starting at the back and going forward. The pad should be applied using a front-to-back motion. Notifying the health care provider of a temperature above 100.4° F (38° C), aiming the peri-bottle spray so that the flow goes from front to back, and reporting danger signs such as chills or lochia with a strange odor indicate effective teaching. Chapter Number: 22 Page: 817

A woman with hyperemesis gravidarum asks the nurse about suggestions to minimize nausea and vomiting. Which suggestion would be most appropriate for the nurse to make? A. "Make sure that anything around your waist is quite snug." B. "Try to eat three large meals a day with less snacking." C. "Drink fluids in between meals rather than with meals." D. "Lie down for about an hour after you eat."

A. "Make sure that anything around your waist is quite snug." B. "Try to eat three large meals a day with less snacking." CorrectC. "Drink fluids in between meals rather than with meals." D. "Lie down for about an hour after you eat." Rationale: Suggestions to minimize nausea and vomiting include avoiding tight waistbands to minimize pressure on the abdomen, eating small frequent meals throughout the day, separating fluids from solids by consuming fluids in between meals; and avoiding lying down or reclining for at least 2 hours after eating. Chapter 19

After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful? A. "My blood pressure will continue to be increased for about 6 more months." B. "I won't use my birth control pills for at least a year or two." C. "My intake of iron will have to be closely monitored for 6 months." D. "I will be sure to avoid getting pregnant for at least 1 year."

A. "My blood pressure will continue to be increased for about 6 more months." B. "I won't use my birth control pills for at least a year or two." C. "My intake of iron will have to be closely monitored for 6 months." CorrectD. "I will be sure to avoid getting pregnant for at least 1 year." Rationale: After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial hCG levels are monitored closely for one year, and the client is urged to avoid pregnancy for 1 year because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not important aspects of follow-up after evacuation of a hydatiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided. Chapter 19

A nurse is teaching a woman about measures to prevent preterm labor in future pregnancies because the woman just experienced preterm labor with her most recent pregnancy. The nurse determines that the teaching was successful based on which statement by the woman? A. "Separating pregnancies by about a year should be helpful." B. "Stress isn't a problem that is related to preterm labor." C. "I'll need extra iron in my diet so I have a extra for the baby." D. "I'll make sure to limit the amount of long distance traveling I do."

A. "Separating pregnancies by about a year should be helpful." B. "Stress isn't a problem that is related to preterm labor." C. "I'll need extra iron in my diet so I have a extra for the baby." CorrectD. "I'll make sure to limit the amount of long distance traveling I do." Rationale: Appropriate measures to reduce the risk for preterm labor include: avoiding travel for long distances in cars, trains, planes or buses; achieving adequate iron store through balanced nutrition (excess iron is not necessary); waiting for at least 18 months between pregnancies, and using stress management techniques for stress. Chapter 21

After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A. "We need to get family members to donate blood for transfusion." B. "Our newborn could develop a learning disability later on." C. "Once the bleeding ceases, there won't be any more worries." D. "We'll make sure to cover both of his eyes to protect them."

A. "We need to get family members to donate blood for transfusion." CorrectB. "Our newborn could develop a learning disability later on." C. "Once the bleeding ceases, there won't be any more worries." D. "We'll make sure to cover both of his eyes to protect them."

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? A. "What has helped you to deal with stressful situations in the past?" B. "Let me tell you about what you will see when you visit your baby." C. "Forget about what's happened in the past, and focus on the now." D. "I'll be here to help you all along the way."

A. "What has helped you to deal with stressful situations in the past?" B. "Let me tell you about what you will see when you visit your baby." CorrectC. "Forget about what's happened in the past, and focus on the now." D. "I'll be here to help you all along the way." Rationale: Instead of telling the parents to forget about what has happened, the nurse should review with them the events that have occurred since birth to help them understand and clarify any misconceptions they might have. Other helpful interventions would include telling the parents that the nurse will be with them because this provides them with a physical presence and support; asking about previous coping strategies that worked so that they can use them now; and explaining what is happening and all the equipment being used so they can understand the situation. Chapter 23

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate? A. "Why are you crying?" B. "A baby still wasn't formed in your uterus." C. "I'm sorry you lost your baby." D. "Will a pill help your pain?"

A. "Why are you crying?" B. "A baby still wasn't formed in your uterus." CorrectC. "I'm sorry you lost your baby." D. "Will a pill help your pain?" Telling the client that the nurse is sorry for the loss acknowledges the loss to the woman, validates her feelings, and brings the loss into reality. Asking why the client is crying is ineffective at this time. Offering a pill for the pain ignores the client's feelings. Telling the client that the baby was not formed is inappropriate and discounts any feelings or beliefs that the client has. Chapter Number: 19

A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which statement by the nurse would be most appropriate?

A. "You'll probably have a cesarean birth to prevent exposing your newborn." B. "Antibodies cross the placenta and provide immunity to the newborn." Correct- C. "Antiretroviral medications are available to help reduce the risk of transmission." D. "Wait until after the infant is born, and then something can be done."

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. Which level would the nurse identify as therapeutic? A. 10.8 mEq/L B. 6.1 mEq/L C. 3.3 mEq/L D. 8.4 mEq/L

A. 10.8 mEq/L CorrectB. 6.1 mEq/L C. 3.3 mEq/L D. 8.4 mEq/L Response Feedback: Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic. Chapter Number: 19 Page: 676

When assessing a pregnant woman with heart disease throughout the antepartal period, the nurse would be especially alert for signs and symptoms of cardiac decompensation at which time? A. 16 to 20 weeks' gestation B. 24 to 28 weeks' gestation C. 28 to 32 weeks' gestation D. 20 to 24 weeks' gestation

A. 16 to 20 weeks' gestation B. 24 to 28 weeks' gestation CorrectC. 28 to 32 weeks' gestation D. 20 to 24 weeks' gestation A pregnant woman with heart disease is most vulnerable for cardiac decompensation from 28 to 32 weeks' gestation. Chapter Number: 20

A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus infection in the client who is at: A. 28 weeks' gestation. B. 16 weeks' gestation. C. 32 weeks' gestation. D. 36 weeks' gestation.

A. 28 weeks' gestation. B. 16 weeks' gestation. C. 32 weeks' gestation. CorrectD. 36 weeks' gestation. Rationale: According to the CDC guidelines, all pregnant women should be screened for group B streptococcus infection at 35 to 37 weeks' gestation. Chapter 20

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. Which level would the nurse identify as therapeutic? A. 3.3 mEq/L B. 6.1 mEq/L C. 10.8 mEq/L D. 8.4 mEq/L

A. 3.3 mEq/L CorrectB. 6.1 mEq/L C. 10.8 mEq/L D. 8.4 mEq/L Rationale: Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic. Chapter 19

The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth? A. 6 B. 3 C. 8 D. 11

A. 6 B. 3 C. 8 CorrectD. 11 The Bishop score helps identify women who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score: a score over 8 indicates a successful vaginal birth. Therefore, the woman with a Bishop score of 11 would have the greatest chance for success. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction. Chapter Number: 21

A postpartum woman is ordered to receive oxytocin to stimulate the uterus to contract. Which action would be most important for the nurse to do? A. Administer the drug as an IV bolus injection. B. Piggyback the IV infusion into a primary line. C. Withhold the drug if the woman is hypertensive. D. Give as a vaginal or rectal suppository.A. Administer the drug as an IV bolus injection.

A. Administer the drug as an IV bolus injection. CorrectB. Piggyback the IV infusion into a primary line. C. Withhold the drug if the woman is hypertensive. D. Give as a vaginal or rectal suppository. Rationale: When giving oxytocin, it should be diluted in a liter of IV solution and the infusion set up to be piggy-backed into a primary line to ensure that the medication can be discontinued readily if hyperstimulation or adverse effects occur. It should never be given as an IV bolus injection. Oxytocin may be given if the woman is hypertensive. Oxytocin is not available as a vaginal or rectal suppository. Chapter 22

A nurse is reviewing the medical record of a newborn who has been diagnosed with bronchopulmonary dysplasia. Which factor would the nurse most likely identify as being associated with this condition? A. African American race B. birth before 36 weeks C. male gender D. atrial septal defect

A. African American race B. birth before 36 weeks CorrectC. male gender D. atrial septal defect Male gender is more commonly associated with bronchopulmonary dysplasia. Preterm birth of less than 32 weeks' gestation, sepsis, white race, excessive fluid intake during the first few days of life, severe RDS with mechanical ventilation for more than 1 week, and patent ductus arteriosus are all risk factors associated with chronic lung disease in the newborn. Chapter Number: 24

Which information would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice? A. Both are treated with exchange transfusions of maternal O- blood. CorrectB. Pathologic jaundice appears within 24 hours after birth. C. Physiologic jaundice requires transfer to the NICU. D. Physiologic jaundice results in kernicterus.

A. Both are treated with exchange transfusions of maternal O- blood. CorrectB. Pathologic jaundice appears within 24 hours after birth. C. Physiologic jaundice requires transfer to the NICU. D. Physiologic jaundice results in kernicterus. Pathologic jaundice appears within 24 hours after birth whereas physiologic jaundice commonly appears around the third to fourth days of life. Kernicterus is more commonly associated with pathologic jaundice. An exchange transfusion is used only if the total serum bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic jaundice often is treated at home. Chapter Number: 24

A nurse is providing care to a LGA newborn. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dL. Which action would the nurse do first? A. Feed the newborn 2 ounces of formula. B. Initiate blow-by oxygen therapy. C. Administer intravenous glucose immediately. D. Place the newborn under a radiant warmer.

A. Feed the newborn 2 ounces of formula. B. Initiate blow-by oxygen therapy. CorrectC. Administer intravenous glucose immediately. D. Place the newborn under a radiant warmer. Rationale: If an LGA newborn's blood glucose level is below 25 mg/dL, the nurse should institute immediate treatment with intravenous glucose regardless of the clinical symptoms. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dL. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress. Chapter 23

A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next? A. Massage the uterine fundus. B. Apply warm soaks to the area. C. Notify the health care provider. D. Encourage the client to void.

A. Massage the uterine fundus. B. Apply warm soaks to the area. CorrectC. Notify the health care provider. D. Encourage the client to void. Response Feedback: The client is experiencing postpartum hemorrhage secondary to a perineal hematoma. The nurse needs to notify the health care provider about these findings to prevent further hemorrhage. Applying warm soaks to the area would do nothing to control the bleeding. With a perineal hematoma, the uterus is firm, so massaging the uterus or encouraging the client to void would not be appropriate. Chapter Number: 22 Page: 805

After determining that a newborn is in need of resuscitation, the nurse would perform which action first? A. Suction the airway. B. Administer ventilations. C. Give volume expanders. D. Dry the newborn thoroughly.

A. Suction the airway. B. Administer ventilations. C. Give volume expanders. CorrectD. Dry the newborn thoroughly. Rationale: If resuscitation is needed, the nurse must first stabilize the newborn by drying the newborn thoroughly with a warm towel and provide warmth by placing him or her under a radiant heater to prevent rapid heat loss. Next the newborn's head is placed in a neutral position to open the airway, and the airway is cleared with a bulb syringe or suction catheter. Breathing is stimulated. Often handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respirations. Next ventilations and then chest compressions are done. Administration of epinephrine and/or volume expanders is the last step. Chapter 23

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A. Suggest that the parents stay for just a few minutes to reduce their anxiety. B. Discuss the care they will be giving the newborn upon discharge. C. Encourage the parents to touch their preterm newborn. D. Reassure them that their newborn is progressing well.

A. Suggest that the parents stay for just a few minutes to reduce their anxiety. B. Discuss the care they will be giving the newborn upon discharge. CorrectC. Encourage the parents to touch their preterm newborn. D. Reassure them that their newborn is progressing well. Rationale: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated. Chapter 23

A nurse is preparing a presentation for a group of neonatal nurses on congenital clubfoot. The nurse determines that the presentation was successful when the group makes which statement? A. The intrinsic form can be manually reduced. B. Clubfoot is a common genetic disorder. C. The exact cause of clubfoot is not known. D. The condition affects girls more often than boys.

A. The intrinsic form can be manually reduced. B. Clubfoot is a common genetic disorder. CorrectC. The exact cause of clubfoot is not known. D. The condition affects girls more often than boys. Clubfoot is a complex, multifactorial deformity with genetic and intrauterine factors. Heredity and race seem to factor into the incidence, but the means of transmission and the etiology are unknown. Most newborns with clubfoot have no identifiable genetic, syndromal, or extrinsic cause. Clubfoot affects boys twice as often as girls. With the intrinsic type, manual reduction is not possible. Chapter Number: 24

A client is experiencing postpartum hemorrhage, and the nurse begins to massage her fundus. Which action would be most appropriate for the nurse to do when massaging the woman's fundus? A. Use an up-and-down motion to massage the uterus. B. Wait until the uterus is firm to express clots. C. Continue massaging the uterus for at least 5 minutes. D. Place the hands on the sides of the abdomen to grasp the uterus.

A. Use an up-and-down motion to massage the uterus. CorrectB. Wait until the uterus is firm to express clots. C. Continue massaging the uterus for at least 5 minutes. D. Place the hands on the sides of the abdomen to grasp the uterus. Response Feedback: The uterus must be firm before attempts to express clots are made because application of firm pressure on an uncontracted uterus could lead to uterine inversion. One hand is placed on the fundus and the other hand is placed on the area above the symphysis pubis. Circular motions are used for massage. There is no specified amount of time for fundal massage. Uterine tissue responds quickly to touch, so it is important not to overmassage the fundus. Chapter Number: 22 Page: 806

The health care provider orders PGE2 for a woman to help evacuate the uterus following a spontaneous abortion. Which action would be most important for the nurse to do? A. Use clean technique to administer the drug. B. Maintain the client supine for 1/2 hour after administration. C. Administer intramuscularly into the deltoid area. D. Keep the gel cool until ready to use.

A. Use clean technique to administer the drug. CorrectB. Maintain the client supine for 1/2 hour after administration. C. Administer intramuscularly into the deltoid area. D. Keep the gel cool until ready to use. Rationale: When PGE2 is ordered, the gel should come to room temperature before administering it. Sterile technique should be used, and the client should remain supine for 30 minutes after administration. RhoGAM is administered intramuscularly into the deltoid area. Chapter 19

A nurse is reading a journal article about cesarean births and the indications for them. Which indication for cesarean birth occurs most frequently? A. abnormal fetal heart rate tracing B. labor dystocia C. multiple gestation D. fetal malpresentation

A. abnormal fetal heart rate tracing CorrectB. labor dystocia C. multiple gestation D. fetal malpresentation Rationale: The most common indications for primary cesarean births include, in order of frequency, labor dystocia, abnormal fetal heart rate tracing, fetal malpresentation, multiple gestation, and super macrosomia. Chapter 21

A nurse is conducting a review class for a group of perinatal nurses working at the local clinic. The clinic sees a high population of women who are HIV positive. After discussing the recommendations for antiretroviral therapy with the group, the nurse determines that the teaching was successful when the group identifies which rationale as the underlying principle for the therapy? A. adjunct therapy to radiation and chemotherapy B. can cure acute HIV/AIDS infections C. reduction in viral loads in the blood D. treatment of opportunistic infections

A. adjunct therapy to radiation and chemotherapy B. can cure acute HIV/AIDS infections CorrectC. reduction in viral loads in the blood D. treatment of opportunistic infections Drug therapy is the mainstay of treatment and is important in reducing the viral load as much as possible. Antiretroviral agents do not treat opportunistic infections and are not adjunctive therapy. There is no cure for HIV/AIDS. Chapter Number: 20

Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance? A. alcohol B. cocaine C. marijuana D. heroin

A. alcohol CorrectB. cocaine C. marijuana D. heroin Rationale: Cocaine use produces vasoconstriction, tachycardia, and hypertension in both the mother and fetus. The effects of marijuana are not yet fully understood. Alcohol ingestion would lead to cognitive and behavioral problems in the newborn. Heroin is a central nervous system depressant. Chapter 20

A nurse is preparing a teaching program for a group of pregnant women about preventing infections during pregnancy. When describing measures for preventing cytomegalovirus infection, which measure would the nurse most likely include? A. antibody titer screening B. prenatal screening C. immunization D. frequent handwashing

A. antibody titer screening B. prenatal screening C. immunization CorrectD. frequent handwashing Most women are asymptomatic and don't know they have been exposed to CMV. Prenatal screening for CMV infection is not routinely performed. Since there is no therapy that prevents or treats CMV infections, nurses are responsible for educating and supporting childbearing-age women at risk for CMV infection. Stressing the importance of good handwashing and use of sound hygiene practices can help to reduce transmission of the virus. There is no immunization for CMV. Antibody titer levels would be useful for identifying women at risk for rubella. Chapter Number: 20

A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor. The nurse would be alert for which possible effect in the newborn? A. asphyxia B. cephalhematoma C. central nervous system injury D. clavicular fracture

A. asphyxia CorrectB. cephalhematoma C. central nervous system injury D. clavicular fracture Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes, but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor. Chapter Number: 21

A woman at 10 weeks gestation comes to the clinic for an evaluation. Which finding might lead the nurse to suspect gestational trophoblastic disease? A. blood pressure of 120/84 mm Hg B. report of frequent mild nausea C. fundal height measurement of 18 cm D. history of bright red spotting 6 weeks ago

A. blood pressure of 120/84 mm Hg B. report of frequent mild nausea CorrectC. fundal height measurement of 18 cm D. history of bright red spotting 6 weeks ago Rationale: Findings with gestational trophoblastic disease (hydatidiform mole) may include uterine size larger than expected. Mild nausea would be a normal finding at 10 weeks' gestation. Blood pressure of 120/84 would not be associated with hydatidiform mole and depending on the woman's baseline blood pressure may be within acceptable parameters for her. Bright red spotting might suggest a spontaneous abortion. Chapter 19

A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which finding would the lead the nurse to suspect that the client is having an adverse effect associated with this drug? A. blurred vision B. tachycardia C. gastrointestinal bleeding D. sweating

A. blurred vision CorrectB. tachycardia C. gastrointestinal bleeding D. sweating Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation, tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding, blurred vision, or sweating. Magnesium sulfate may cause sweating. Chapter Number: 19

A woman developed abruptio placenta during the birth of her neonate. The nurse would monitor the client closely for changes. Which finding would be a cause for alarm? A. board-like abdomen B. inversion of the uterus C. severe uterine pain D. appearance of petechiae

A. board-like abdomen B. inversion of the uterus C. severe uterine pain CorrectD. appearance of petechiae A complication of abruptio placentae is disseminated intravascular coagulation (DIC), which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe uterine pain, a board-like abdomen, and uterine inversion are not associated with abruptio placentae. Chapter Number: 22

A nurse is preparing an inservice education program for a group of nurses about dystocia involving problems with the passenger. Which problem would the nurse most likely include as the most common? A. breech presentation B. macrosomia C. multifetal pregnancy D. persistent occiput posterior position

A. breech presentation B. macrosomia C. multifetal pregnancy CorrectD. persistent occiput posterior position Common problems involving the passenger include occiput posterior position, breech presentation, multifetal pregnancy, excessive size (macrosomia) as it relates to cephalopelvic disproportion (CPD), and structural anomalies. Of these, persistent occiput posterior is the most common malposition, occurring in about 15% of laboring women. Chapter Number: 21

A nurse is reviewing a journal article on the causes of postpartum hemorrhage. Which condition would the nurse most likely find as the most common cause? A. cervical or vaginal lacerations B. uterine atony C. labor augmentation D. uterine inversion

A. cervical or vaginal lacerations CorrectB. uterine atony C. labor augmentation D. uterine inversion The most common cause of postpartum hemorrhage is uterine atony, failure of the uterus to contract and retract after birth. The uterus must remain contracted after birth to control bleeding from the placental site. Labor augmentation is a risk factor for postpartum hemorrhage. Lacerations of the birth canal and uterine inversion may cause postpartum hemorrhage, but these are not the most common cause. Chapter Number: 22

A woman who is 42 weeks pregnant comes to the clinic. During the visit, which assessment would be most important for the nurse to perform? A. checking for spontaneous rupture of membranes B. asking her about the occurrence of contractions C. measuring the height of the fundus D. determining an accurate gestational age

A. checking for spontaneous rupture of membranes B. asking her about the occurrence of contractions C. measuring the height of the fundus CorrectD. determining an accurate gestational age Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks. Chapter Number: 21

A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse determines that additional teaching is needed when the mother identifies which action as appropriate for her newborn? A. checking the newborn's fontanels B. wrapping the newborn snugly in a blanket C. offering a pacifier D. waking the newborn every hour

A. checking the newborn's fontanels B. wrapping the newborn snugly in a blanket C. offering a pacifier CorrectD. waking the newborn every hour Rationale: Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration. Chapter 24

The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? A. closed B. shortened C. firm D. posterior position

A. closed CorrectB. shortened C. firm D. posterior position Response Feedback: A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm. Chapter Number: 21 Page: 777

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which condition? A. cold stress B. metabolic acidosis C. retinopathy of prematurity D. infection

A. cold stress B. metabolic acidosis CorrectC. retinopathy of prematurity D. infection Rationale: Oxygen therapy has been linked the pathogenesis of retinopathy of prematurity and is associated with the duration of oxygen use rather than the concentration of oxygen. Therefore, the nurse monitors the newborn's oxygen therapy closely. Metabolic acidosis may occur due to anaerobic metabolism used for heat production. Infection may occur for numerous reasons, but they are unrelated to oxygen therapy. Cold stress results from problems due to the preterm newborn's inadequate supply of brown fat, decreased muscle tone, and large body surface area. Chapter 23

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply. A. constipation B. four to five contractions in 1 hour C. malodorous vaginal discharge D. dysuria E. dull low backache

A. constipation B. four to five contractions in 1 hour CorrectC. malodorous vaginal discharge CorrectD. dysuria CorrectE. dull low backache Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour. chapter 21

A newborn has been diagnosed with a Group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which cause? A. contaminated formula B. mother's birth canal C. nonsterile catheter insertion D. improper handwashing

A. contaminated formula CorrectB. mother's birth canal C. nonsterile catheter insertion D. improper handwashing Rationale: Most often, a newborn develops a Group B streptococcus infection during the birthing process when the newborn comes into contact with an infected birth canal. Improper handwashing, contaminated formula, and nonsterile catheter insertion would most likely lead to a late-onset infection, which typically occurs in the nursery due to horizontal transmission. Chapter 24

A woman with gestational hypertension experiences a seizure. Which intervention would the nurse identify as the priority? A. control of hypertension B. delivery of the fetus C. fluid replacement D. oxygenation

A. control of hypertension B. delivery of the fetus C. fluid replacement CorrectD. oxygenation Rationale: As with any seizure, the priority is to clear the airway and maintain adequate oxygenation both to the mother and the fetus. Fluids and control of hypertension are addressed once the airway and oxygenation are maintained. Delivery of fetus is determined once the seizures are controlled and the woman is stable. chapter 19

A woman with gestational hypertension experiences a seizure. Which intervention would the nurse identify as the priority? A. control of hypertension B. oxygenation C. delivery of the fetus D. fluid replacement

A. control of hypertension CorrectB. oxygenation C. delivery of the fetus D. fluid replacement As with any seizure, the priority is to clear the airway and maintain adequate oxygenation both to the mother and the fetus. Fluids and control of hypertension are addressed once the airway and oxygenation are maintained. Delivery of fetus is determined once the seizures are controlled and the woman is stable. Chapter 19

A nurse is preparing a presentation for a group of perinatal nurses about common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the nurse includes which factor as contributing to the newborn's risk? Select all that apply. A. depleted glycogen stores B. surfactant deficiency C. immaturity of the respiratory control centers D. decreased amounts of brown fat E. placental deprivation

A. depleted glycogen stores CorrectB. surfactant deficiency CorrectC. immaturity of the respiratory control centers D. decreased amounts of brown fat E. placental deprivation Rationale: Preterm newborns are at risk for perinatal asphyxia due to surfactant deficiency, unstable chest wall, immaturity of the respiratory control centers, small respiratory passages, and inability to clear mucus from the airways. Placental deprivation places the post-term newborn at risk for perinatal asphyxia. Decreased amounts of brown fat and depleted glycogen stores place the SGA newborn at risk for problems with thermoregulation. Chapter 23

The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse determines that the women understood the description when they identify the condition as postpartum: A. depression. B. psychosis. C. blues. D. bipolar disorder.

A. depression. B. psychosis. CorrectC. blues. D. bipolar disorder. Response Feedback: Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with childbirth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania. Chapter Number: 22 Page: 819

A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: A. determines that the procedure is effective. B. helps support the lower uterine segment. C. aids in expressing accumulated clots. D. prevents uterine muscle fatigue.

A. determines that the procedure is effective. CorrectB. helps support the lower uterine segment. C. aids in expressing accumulated clots. D. prevents uterine muscle fatigue. Rationale: The nurse places the nondominant hand on the area above the symphysis pubis to help support the lower uterine segment. The hand, usually the dominant hand that is placed on the fundus, helps to determine uterine firmness (and thus the effectiveness of the massage). Applying gentle downward pressure on the fundus helps to express clots. Overmassaging the uterus leads to muscle fatigue. Chapter 22

A multipara client develops thrombophlebitis after delivery. Which assessment finding would lead the nurse to intervene immediately? A. dyspnea, bradycardia, hypertension, and confusion B. weakness, anorexia, change in level of consciousness, and coma C. pallor, tachycardia, seizures, and jaundice D. dyspnea, diaphoresis, hypotension, and chest pain

A. dyspnea, bradycardia, hypertension, and confusion B. weakness, anorexia, change in level of consciousness, and coma C. pallor, tachycardia, seizures, and jaundice CorrectD. dyspnea, diaphoresis, hypotension, and chest pain Rationale: Sudden unexplained shortness of breath and complaints of chest pain along with diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action. Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden change in the woman's mental status secondary to hypoxemia. Anorexia, seizures, and jaundice are unrelated to a pulmonary embolism. Chapter 22

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply. A. dysuria B. malodorous vaginal discharge C. constipation D. four to five contractions in 1 hour E. dull low backache

A. dysuria CorrectB. malodorous vaginal discharge C. constipation D. four to five contractions in 1 hour CorrectE. dull low backache Rationale: Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour. Chapter 21

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority? A. edema B. infection C. jaundice D. hemorrhage

A. edema B. infection C. jaundice CorrectD. hemorrhage rationale: With a ruptured ectopic pregnancy, the woman is at high risk for hemorrhage. Jaundice, edema, and infection are not associated with a ruptured ectopic pregnancy. Chapter 19

The nurse is reviewing the laboratory test results of a pregnant client. Which finding would alert the nurse to the development of HELLP syndrome? A. elevated platelet count B. leukocytosis C. elevated liver enzymes D. hyperglycemia

A. elevated platelet count B. leukocytosis CorrectC. elevated liver enzymes D. hyperglycemia Rationale: HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia or leukocytosis is not a part of this syndrome. Chapter 19

A postpartum woman is diagnosed with metritis. The nurse interprets this as an infection involving which area? Select all that apply. A. fallopian tubes B. ovaries CorrectC. endometrium D. broad ligament E. decidua F. myometrium

A. fallopian tubes B. ovaries CorrectC. endometrium D. broad ligament CorrectE. decidua CorrectF. myometrium Response Feedback: Metritis is an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus. Extension of metritis can result in parametritis, which involves the broad ligament and possibly the ovaries and fallopian tubes, or septic pelvic thrombophlebitis. Chapter Number: 22 Page: 812

A home health care nurse is assessing a postpartum woman who was discharged 2 days ago. The woman tells the nurse that she has a low-grade fever and feels "lousy." Which finding would lead the nurse to suspect metritis? Select all that apply. A. flank pain B. breast tenderness C. urgency D. lower abdominal tenderness E. anorexia

A. flank pain B. breast tenderness C. urgency CorrectD. lower abdominal tenderness CorrectE. anorexia Response Feedback: Manifestations of metritis include lower abdominal tenderness or pain on one or both sides, elevated temperature, foul-smelling lochia, anorexia, nausea, fatigue and lethargy, leukocytosis, and elevated sedimentation rate. Urgency and flank pain would suggest a urinary tract infection. Breast tenderness may be related to engorgement or suggest mastitis. Chapter Number: 22 Page: 815

Assessment of newborn reveals a large protruding tongue, slow reflexes, distended abdomen, poor feeding, hoarse cry, goiter, and dry skin. Which condition would the nurse suspect? A. galactosemia B. congenital hypothyroidism C. phenylketonuria D. maple syrup urine disease

A. galactosemia CorrectB. congenital hypothyroidism C. phenylketonuria D. maple syrup urine disease Rationale: The manifestations listed correlate with congenital hypothyroidism. With phenylketonuria, the infant appears normal at birth, but by 6 months of age, signs of slow mental development are evident. Vomiting, poor feeding, failure to thrive, overactivity, and musty-smelling urine are additional signs. With maple syrup urine disease, signs and symptoms include lethargy, poor feeding, vomiting, weight loss, seizures, shrill cry, shallow respirations, loss of reflexes, and a sweet maple syrup odor to the urine. With galactosemia, manifestations include vomiting, hypoglycemia, hyperbilirubinemia, poor weight gain, cataracts, and frequent infections. Chapter 24

A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which finding would the lead the nurse to suspect that the client is having an adverse effect associated with this drug? A. gastrointestinal bleeding B. blurred vision C. tachycardia D. sweating

A. gastrointestinal bleeding B. blurred vision CorrectC. tachycardia D. sweating Rationale: Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation, tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding, blurred vision, or sweating. Magnesium sulfate may cause sweating. Chapter 19

The nurse would be alert for possible placental abruption during labor when assessment reveals which finding? A. gestational diabetes B. macrosomia C. gestational hypertension D. low parity

A. gestational diabetes B. macrosomia CorrectC. gestational hypertension D. low parity Rationale: Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors. Chapter 21

A nurse is counseling a pregnant woman with rheumatoid arthritis about medications that can be used during pregnancy. Which drug would the nurse emphasize as being contraindicated at this time? A. glucocorticoid B. methotrexate C. hydroxychloroquine D. nonsteroidal anti-inflammatory drugs

A. glucocorticoid CorrectB. methotrexate C. hydroxychloroquine D. nonsteroidal anti-inflammatory drug Rationale: Methotrexate is a FDA Category X drug and is contraindicated during pregnancy. For rheumatoid arthritis, medications are limited to hydroxychloroquine, glucocorticoids, and NSAIDS. Chapter 20

The nurse is assessing a newborn who is large for gestational age. The newborn was born breech. The nurse suspects that the newborn may have experienced trauma to the upper brachial plexus based on which assessment finding? A. hand weakness B. facial asymmetry C. absent Moro reflex D. absent grasp reflex

A. hand weakness B. facial asymmetry CorrectC. absent Moro reflex D. absent grasp reflex Rationale: An injury to the upper brachial plexus, or Erb's palsy, is manifested by adduction, pronation, and internal rotation of the affected extremity, absent shoulder movement, absent Moro reflex and positive grasp reflex. An absent grasp reflex and hand weakness is noted with a lower brachial plexus injury. Facial asymmetry is associated with a cranial nerve injury. Chapter 24

Which information on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy? A. heavy, irregular menses B. use of oral contraceptives for 5 years C. recurrent pelvic infections D. ovarian cyst 2 years ago

A. heavy, irregular menses B. use of oral contraceptives for 5 years CorrectC. recurrent pelvic infections D. ovarian cyst 2 years ago In the general population, most cases of ectopic pregnancy are the result of tubal scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy, irregular menses are not considered risk factors for ectopic pregnancy. Chapter Number: 19

When teaching a class of pregnant women about the effects of substance abuse during pregnancy, the nurse would most likely include which effect? A. higher pain tolerance B. longer gestational periods C. low-birthweight infants D. excessive weight gain

A. higher pain tolerance B. longer gestational periods CorrectC. low-birthweight infants D. excessive weight gain Rationale: Substance abuse during pregnancy is associated with low-birthweight infants, preterm labor, abortion, intrauterine growth restriction, abruptio placentae, neurobehavioral abnormalities, and long-term childhood developmental consequences. Excessive weight gain, higher pain tolerance, and longer gestational periods are not associated with substance abuse. Chapter 20

The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary because: A. hyperbilirubinemia is likely to develop. B. lactase enzymatic activity is not adequate. C. oxygen demands need to be reduced. D. renal solute lead must be considered.

A. hyperbilirubinemia is likely to develop. B. lactase enzymatic activity is not adequate. CorrectC. oxygen demands need to be reduced. D. renal solute lead must be considered. For the newborn with transient tachypnea, the newborn's respiratory rate is high, increasing his oxygen demand. Thus, measures are initiated to reduce this demand. Gavage feedings are one way to do so. With transient tachypnea, enzyme activity and kidney function are not affected. This condition typically resolves within 72 hours. The risk for hyperbilirubinemia is not increased. Chapter Number: 24

As part of an inservice program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn? A. in the first week B. within the first 6 weeks C. within the first 2 weeks D. in approximately 1 month

A. in the first week CorrectB. within the first 6 weeks C. within the first 2 weeks D. in approximately 1 month Rationale: PPD usually has a gradual onset and becomes evident within the first 6 weeks postpartum. Postpartum blues typically manifests in the first week postpartum. Postpartum psychosis usually appears about 3 months after birth of the newborn. Chapter 22

A nurse is assessing a newborn who has been classified as small for gestational age. Which characteristics would the nurse expect to find? Select all that apply A. increased amount of breast tissue B. narrow skull sutures C. adequate muscle tone over buttocks D. wasted extremity appearance E. sunken abdomen

A. increased amount of breast tissue CorrectB. narrow skull sutures C. adequate muscle tone over buttocks CorrectD. wasted extremity appearance CorrectE. sunken abdomen Rationale: Typical characteristics of SGA newborns include a head that is disproportionately large compared to the rest of the body, wasted appearance of the extremities, reduced subcutaneous fat stores, decreased amount of breast tissue, scaphoid abdomen, wide skull sutures, poor muscle tone over buttocks and cheeks, loose and dry skin appearing oversized, and a thin umbilical cord. Chapter 23

The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU) for signs and symptoms of overstimulation. Which sign would the nurse be most likely to assess? A. increased heart rate B. flaying hands C. increased respirations D. eupnea

A. increased heart rate CorrectB. flaying hands C. increased respirations D. eupnea Rationale: Overstimulation may have negative effects by reducing oxygenation and causing stress. A newborn reacts to stress by flaying the hands or bringing an arm up to cover the face. When overstimulated, such as by noise, lights, excessive handling, alarms, and procedures, and stressed, heart and respiratory rates decrease and periods of apnea or bradycardia may occur. Chapter 23

A newborn with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which measure would the nurse anticipate as possibly necessary for this newborn? A. insertion of a laryngoscope for deep suctioning B. extracorporeal membrane oxygenation (ECMO) C. respiratory support with a ventilator D. replacement of an endotracheal tube via X-ray

A. insertion of a laryngoscope for deep suctioning CorrectB. extracorporeal membrane oxygenation (ECMO) C. respiratory support with a ventilator D. replacement of an endotracheal tube via X-ray Rationale: If conventional measures are ineffective, then the nurse would need to prepare the newborn for ECMO. Hyperoxygenation, ventilatory support, and suctioning are typically used initially to promote tissue perfusion. However, if these are ineffective, ECMO would be the next step. Chapter 24

A nurse is developing a plan of care for a newborn with omphalocele. Which measure would the nurse most likely include? A. instituting gavage feedings B. using clean technique for dressing changes C. preparing the newborn for incision and drainage D. placing the newborn into a sterile drawstring bowel bag

A. instituting gavage feedings B. using clean technique for dressing changes C. preparing the newborn for incision and drainage CorrectD. placing the newborn into a sterile drawstring bowel bag Rationale: An infant with an omphalocele is placed in a sterile drawstring bowel bag that maintains a sterile environment for the exposed contents, allows visualization, reduces heat and moisture loss, and allows heat from radiant warmers to reach the newborn. The newborn is placed feet-first into the bag, and the drawstring is secured around the torso. Strict sterile technique is necessary to prevent contamination of the exposed abdominal contents. An orogastric tube attached to low suction is used to prevent intestinal distention. IV therapy is administered to maintain fluid and electrolyte balance and provide a route for antibiotic therapy. Surgery is done to repair the defect not to incise and drain it. Chapter 24

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition? A. laceration B. hematoma C. bladder distention D. uterine atony

A. laceration CorrectB. hematoma C. bladder distention D. uterine atony Rationale: The woman most likely has a hematoma based on the findings: firm uterus with bright-red bleeding; localized bluish bulging area just under the skin surface in the perineal area; severe perineal or pelvic pain; and difficulty voiding. A laceration would involve a firm uterus with a steady stream or trickle of unclotted bright-red blood in the perineum. Bladder distention would be palpable along with a soft, boggy uterus that deviates from the midline. Uterine atony would be noted by a uncontracted uterus. Chapter 22

A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk? A. large-for-gestational-age (LGA) newborns B. appropriate-for-gestational-age (AGA) newborns C. small-for-gestational-age (SGA) newborns D. low-birth-weight newborns

A. large-for-gestational-age (LGA) newborns Correct- B. appropriate-for-gestational-age (AGA) newborns C. small-for-gestational-age (SGA) newborns D. low-birth-weight newborns Rationale: Appropriate-for-gestational-age (AGA) newborns are at the lowest risk for any problems. AGA characterizes approximately 80% of newborns and describes a newborn with a normal length, weight, head circumference, and body mass index. The other categories all have an increased risk of complications. Chapter 23

A pregnant client whose diabetes has been poorly controlled throughout her pregnancy is in labor. The nurse would assess the neonate closely at birth for which condition? A. low birthweight B. macrosomia C. hyperglycemia D. hypobilirubinemia

A. low birthweight CorrectB. macrosomia C. hyperglycemia D. hypobilirubinemia Poorly controlled diabetes during pregnancy can result in macrosomia due to hyperinsulinemia stimulated by fetal hyperglycemia. Typically the neonate is hypoglycemic due to the ongoing hyperinsulinemia that occurs after the placenta is removed. Infants of diabetic women typically are large and are at risk for hyperbilirubinemia due to excessive red blood cell breakdown. Chapter Number: 20

A nurse is providing education to a woman who is experiencing postpartum hemorrhage and is to receive a uterotonic agent. The nurse determines that additional teaching is needed when the woman identifies which drug as treating postpartum hemorrhage? A. methylergonovine B. terbutaline C. oxytocin D. carboprost

A. methylergonovine CorrectB. terbutaline C. oxytocin D. carboprost Rationale: Terbutaline is a tocolytic agent that may be used to halt preterm labor. It would not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage. Chapter 22

A woman pregnant with twins comes to the clinic for an evaluation. The nurse closely assesses the client for which potential problem? A. oligohydramnios B. post-term labor C. chorioamnionitis D. preeclampsia

A. oligohydramnios B. post-term labor C. chorioamnionitis CorrectD. preeclampsia Rationale: Women with multiple gestations are at high risk for preeclampsia, preterm labor, polyhydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis. Chapter 19

A nurse is presenting a review class for a group of neonatal nurses about congenital heart disease. The nurse determines that the teaching was effective when the class identifies which condition as associated with decreased pulmonary blood flow? A. patent ductus arteriosus B. tetralogy of Fallot C. atrial septal defect D. ventricular septal defect

A. patent ductus arteriosus CorrectB. tetralogy of Fallot C. atrial septal defect D. ventricular septal defect Rationale: Tetralogy of Fallot is a congenital heart condition that results from decreased, not increased, pulmonary blood flow. Atrial septal defect, ventricular septal defect, and patent ductus arteriosus are heart conditions that involve increased blood flow from higher pressure (left side of heart) to lower pressure (right side of heart), resulting in left-to-right shunting. Chapter 24

A nurse is teaching the mother of a newborn diagnosed with galactosemia about dietary restrictions. The nurse determines that the mother has understood the teaching when she identifies which of the following as needing to be restricted? A. phenylalanine B. iodine C. lactose D. protein

A. phenylalanine B. iodine CorrectC. lactose D. protein rationale: Lifelong restriction of lactose is required for galactosemia. Phenylalanine is restricted for those with phenylketonuria. Low protein is needed with maple syrup urine disease. Iodine would not be restricted for any inborn error of metabolism. Chapter 24

The fetus of a woman in labor is determined to be in persistent occiput posterior position. Which intervention would the nurse identify as the priority? A. position changes B. immediate cesarean birth C. pain relief measures D. oxytocin administration

A. position changes B. immediate cesarean birth CorrectC. pain relief measures D. oxytocin administration Rationale: Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and backrubs may be helpful. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman's already high level of pain. Chapter 21

The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was delivered at 35 weeks' gestation. How would the nurse classify this newborn? A. preterm B. post-term C. late preterm D. full term

A. preterm B. post-term CorrectC. late preterm D. full term Rationale: A late preterm infant is one born between 34 to 36 weeks of gestation. A preterm infant is one born before 37 completed weeks' gestation. A full-term infant is one born between 38 to 41 weeks' gestation. A post-term newborn is one born at 42 weeks' gestation or later. Chapter 23

A nurse is developing the plan of care for an SGA newborn. Which action would the nurse determine as a priority? A. promoting bonding between the parents and the newborn B. preventing hypoglycemia with early feedings C. observing for respiratory distress syndrome D. monitoring vital signs every 2 hours

A. promoting bonding between the parents and the newborn CorrectB. preventing hypoglycemia with early feedings C. observing for respiratory distress syndrome D. monitoring vital signs every 2 hours rationale: With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn. Chapter 23

The nurse is assessing a newborn of a woman who is suspected of abusing alcohol. Which newborn finding would provide additional evidence to support this suspicion? A. protruding jaw B. wide, large eyes C. thin upper lip D. elongated nose

A. protruding jaw B. wide, large eyes CorrectC. thin upper lip D. elongated nose Rationale: Newborn characteristics suggesting fetal alcohol spectrum disorder include thin upper lip, small head circumference, small eyes, receding jaw, and short nose. Other features include a low nasal bridge, short palpebral fissures, flat midface, epicanthal folds, and minor ear abnormalities. Chapter 20

A nurse is providing care to a newborn who is receiving phototherapy. Which action would the nurse most likely include in the plan of care? A. reducing the amount of fluid intake to 8 ounces daily B. ensuring that the newborn is covered or clothed C. keeping the newborn in the supine position D. covering the newborn's eyes while under the bililights

A. reducing the amount of fluid intake to 8 ounces daily B. ensuring that the newborn is covered or clothed C. keeping the newborn in the supine position CorrectD. covering the newborn's eyes while under the bililights Rationale: During phototherapy, the newborn's eyes are covered to protect them from the lights. The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid intake is increased to allow for added fluid, protein, and calories. Chapter 24

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A. respiratory rate of 16 breaths per minute B. urine output of 45 mL/hour C. diminished deep tendon reflexes D. alert level of consciousness

A. respiratory rate of 16 breaths per minute B. urine output of 45 mL/hour CorrectC. diminished deep tendon reflexes D. alert level of consciousness Rationale: Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness. Chapter 21

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A. respiratory rate of 16 breaths per minute B. diminished deep tendon reflexes C. alert level of consciousness D. urine output of 45 mL/hour

A. respiratory rate of 16 breaths per minute CorrectB. diminished deep tendon reflexes C. alert level of consciousness D. urine output of 45 mL/hour Rationale: Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness. Chapter 21

A nurse is preparing a presentation for a group of young adult pregnant women about common infections and their effect on pregnancy. When describing the infections, which infection would the nurse include as the most common congenital and perinatal viral infection in the world? A. rubella B. hepatitis B C. parvovirus B19 D. cytomegalovirus

A. rubella B. hepatitis B C. parvovirus B19 CorrectD. cytomegalovirus Rationale: Although rubella, hepatitis B, and parovirus B19 can affect pregnant women and their fetuses, cytomegalovirus (CMV) is the most common congenital and perinatal viral infection in the world. CMV is the leading cause of congenital infection, with morbidity and mortality at birth and sequelae. Each year approximately 1% to 7% of pregnant women acquire a primary CMV infection. Of these, about 30% to 40% transmits infection to their fetuses. Chapter 20

A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect? A. shoulder dystocia B. uterine rupture C. amniotic fluid embolism D. umbilical cord prolapse

A. shoulder dystocia CorrectB. uterine rupture C. amniotic fluid embolism D. umbilical cord prolapse Rationale: Uterine rupture is associated with crack cocaine use, and generally the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus. Chapter 21

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which characteristic would the nurse correlate with this gestational age variation? A. strong, brisk motor skills B. birthweight of 7 lb 14 oz (3,572 g) C. wasted appearance of extremities D. difficulty in arousing to a quiet alert state

A. strong, brisk motor skills B. birthweight of 7 lb 14 oz (3,572 g) C. wasted appearance of extremities CorrectD. difficulty in arousing to a quiet alert state LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz (3,997 g) at term. Chapter Number: 23

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A. supine B. sitting C. side-lying D. knee-chest

A. supine B. sitting C. side-lying CorrectD. knee-chest Rationale: Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression. Chapter 21

A nurse is conducting an in-service presentation to a group of perinatal nurses about sexually transmitted infections and their effect on pregnancy. The nurse determines that the teaching was successful when the group identifies which infection as being responsible for ophthalmia neonatorum? A. syphilis B. HPV C. chlamydia D. gonorrhea

A. syphilis B. HPV C. chlamydia CorrectD. gonorrhea Rationale: Infection with gonorrhea during pregnancy can cause ophthalmia neonatorum in the newborn from birth through an infected birth canal. Infection with syphilis can cause congenital syphilis in the neonate. Infection with chlamydia can lead to conjunctivitis or pneumonia in the newborn. Exposure to HPV during birth is associated with laryngeal papillomas.

Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which finding would the nurse expect to assess? Select all that apply. A. tachycardia B. cool extremities C. diaphoresis D. oliguria E. confusion

A. tachycardia CorrectB. cool extremities CorrectC. diaphoresis D. oliguria E. confusion Response Feedback: Signs and symptoms of mild shock include diaphoresis, increased capillary refill, cool extremities, and maternal anxiety. Tachycardia and oliguria suggest moderate shock. Confusion suggests severe shock. Chapter Number: 22 Page: 801

When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because: A. they relate more to change in condition than to the amount of blood lost. B. maternal anxiety adversely affects these vital signs. C. these measurements may not change until after the blood loss is large. D. the body's compensatory mechanisms activate and prevent any changes.

A. they relate more to change in condition than to the amount of blood lost. B. maternal anxiety adversely affects these vital signs. CorrectC. these measurements may not change until after the blood loss is large. D. the body's compensatory mechanisms activate and prevent any changes. Rationale: The typical signs of hemorrhage do not appear in the postpartum woman until as much as 1,800 to 2,100 mL of blood has been lost. In addition, accurate determination of actual blood loss is difficult because of blood pooling inside the uterus and on perineal pads, mattresses, and the floor. Chapter 22

While reviewing a newborn's medical record, the nurse notes that the chest X-ray shows a ground glass pattern. The nurse interprets this as indicative of: A. transient tachypnea of the newborn. B. respiratory distress syndrome. C. persistent pulmonary hypertension. D. asphyxia.

A. transient tachypnea of the newborn. CorrectB. respiratory distress syndrome. C. persistent pulmonary hypertension. D. asphyxia. Rationale: The chest X-ray of a newborn with RDS reveals a reticular (ground glass) pattern. For TTN, the chest X-ray shows lung overaeration and prominent perihilar interstitial markings and streakings. A chest X-ray for asphyxia would reveal possible structural abnormalities that might interfere with respiration, but the results are highly variable. An echocardiogram would be done to evaluate persistent pulmonary hypertension Chapter 24

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A. urine output of 45 mL/hour B. alert level of consciousness C. diminished deep tendon reflexes D. respiratory rate of 16 breaths per minute

A. urine output of 45 mL/hour B. alert level of consciousness CorrectC. diminished deep tendon reflexes D. respiratory rate of 16 breaths per minute Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness. Chapter Number: 21

A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition? A. uterine bleeding B. fetopelvic disproportion C. a low-lying placenta D. contraction ring

A. uterine bleeding CorrectB. fetopelvic disproportion C. a low-lying placenta D. contraction ring Rationale: The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern. Chapter 21

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition? A. uterine subinvolution CorrectB. thrombophlebitis C. retained placental fragments D. hypertension

A. uterine subinvolution CorrectB. thrombophlebitis C. retained placental fragments D. hypertension The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased amount of time in bed, and venous pooling that occurs when the woman's legs are in stirrups for a long period of time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or hypertension. Chapter Number: 22

A nurse is conducting a class for expectant parents about newborns. As part of the class the nurse describes newborns with birth-weight variations. The nurse identifies which variation if the newborn weighs 5.2 lb (2,358 g) at any gestational age? A. very low birth weight B. low birth weight C. small for gestational age D. extremely low birth weight

A. very low birth weight CorrectB. low birth weight C. small for gestational age D. extremely low birth weight Rationale: A low-birth-weight newborn weighs less than 5.5 lb (2,500 g) but more than 3 lb 5 oz (1,587 g). A very-low-birth-weight newborn would weigh less than 3 lb 5 oz (1,587 g) but more than 2 lb 3 oz (1,000 g). An extremely-low-birth-weight newborn weighs less than 2 lb 3 oz (1,000 g). A small-for-gestational-age newborn typically weighs less than 5 lb 8 oz (2,500 g) at term. Chapter 23

A nurse is providing care to newborn. The nurse suspects that the newborn is developing sepsis based on which assessment finding? A. wakefulness B. interest in feeding C. increased urinary output D. temperature instability

A. wakefulness B. interest in feeding C. increased urinary output CorrectD. temperature instability Rationale: Manifestations of sepsis are typically nonspecific and may include hypothermia (temperature instability), oliguria or anuria, lack of interest in feeding, and lethargy. Chapter 24

A a nurse is conducting a presentation for a group of pregnant women about measures to prevent toxoplasmosis. The nurse determines that additional teaching is needed when the group identifies which measure as preventative? A. washing raw fruits and vegetables before eating them B. wearing gardening gloves when working in the soil C. cooking all meat to an internal temperature of 140° F D. avoiding contact with a cat's litter box

A. washing raw fruits and vegetables before eating them B. wearing gardening gloves when working in the soil CorrectC. cooking all meat to an internal temperature of 140° F D. avoiding contact with a cat's litter box Rationale: Meats should be cooked to an internal temperature of 160° F. Other measures to prevent toxoplasmosis include peeling or thoroughly washing all raw fruits and vegetables before eating them, wearing gardening gloves when in contact with outdoor soil, and avoiding the emptying or cleaning of a cat's litter box. Chapter 20

After teaching a pregnant woman with iron deficiency anemia about nutrition, the nurse determines that the teaching was successful when the woman identifies which food as being good sources of iron in her diet? Select all that apply. A. white bread B. peanut butter C. milk D. meats E. dried fruits

A. white bread CorrectB. peanut butter C. milk CorrectD. meats CorrectE. dried fruits Rationale: Foods high in iron include meats, green leafy vegetables, legumes, dried fruits, whole grains, peanut butter, bean dip, whole-wheat fortified breads, and cereals. Chapter 20

A pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose level. When reviewing the results, the nurse determines that which result indicates good glucose control? A. 120 mg/dL B. 100 mg/dL C. 110 mg/dL D. 88 mg/dL

CORRECT = D) 88 mg/dL Rationale: For a pregnant woman with diabetes, the ADA (2012b) recommends maintaining a fasting blood glucose level below 92 mg/dL, with postprandial levels below 180 mg/dL and 2-hour postprandial levels below 153 mg/dL. Chapter 20

A woman who is 42 weeks pregnant comes to the clinic. During the visit, which assessment would be most important for the nurse to perform? A. checking for spontaneous rupture of membranes B. asking her about the occurrence of contractions C. measuring the height of the fundus D. determining an accurate gestational age

CORRECT = D) determining an accurate gestational age. Rationale: Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks. Chapter 21

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? A. well-developed flexor muscles in the extremities B. more subcutaneous fat in the neck and abdomen C. fewer visible blood vessels through the skin D. greater surface area in proportion to weight

CORRECT = D) greater surface area in proportion to weight Rationale: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone. Chapter 23

A nurse is teaching a woman with mild preeclampsia about important areas that she needs to monitor. The nurse determines that the teaching was successful based on which statement by the woman? Select all that apply. A. "I'll call my health care provider if I have burning when I urinate." B. "I will weigh myself once a week." C. "I will check my urine for protein four times a day." D. "I should check my blood pressure twice a day." E. "I should complete a fetal kick count each day.

CORRECT: A) I'll call my health care provider if I have burning when I urinate; D) I should check my blood pressure twice a day; E) I should complete a fetal kick count each day Rationale: The client should take her blood pressure twice daily, check and record weight daily, perform urine dipstick checks for protein twice daily, record the number of fetal kicks daily, and notify her health care provider is she experiences burning on urination. Chapter 19

Which information would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice? A. Pathologic jaundice appears within 24 hours after birth. B. Both are treated with exchange transfusions of maternal O- blood. C. Physiologic jaundice requires transfer to the NICU. D. Physiologic jaundice results in kernicterus.

CORRECT: A) Pathologic jaundice appears within 24 hours after birth. Rationale: Pathologic jaundice appears within 24 hours after birth whereas physiologic jaundice commonly appears around the third to fourth days of life. Kernicterus is more commonly associated with pathologic jaundice. An exchange transfusion is used only if the total serum bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic jaundice often is treated at home. Chapter 24

Which measure would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A. Provide opportunities for them to hold the newborn. B. Avoid using the terms "death" or "dying." C. Refrain from initiating conversations with the parents. D. Quickly refocus the parents to a more pleasant topic.

CORRECT: A) Provide opportunities for them to hold the newborn. Rationale: When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process. Chapter 23

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which findings would support the nurse's suspicion? Select all that apply. A. shallow, slow respirations B. irritability C. feeble cry D. hypertonicity E. cyanotic hands and feet

CORRECT: A) shallow, slow respirations; C) feeble cry; E) cyanotic hands and feet Rationale: Typically, a preterm newborn that is having problems with thermal regulation is cool to cold to the touch. The hands, feet, and tongue may appear cyanotic. Respirations are shallow or slow, or signs of respiratory distress are present. The newborn is lethargic and hypotonic, feeds poorly, and has a feeble cry. Blood glucose levels are probably low, leading to hypoglycemia, due to the energy expended to keep warm. Chapter 23

A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which finding would lead the nurse to suspect that the woman is developing an infection? Select all that apply. A. decreased C-reactive protein levels B. abdominal tenderness C. fetal bradycardia D. elevated maternal pulse rate E. cloudy malodorous fluid

CORRECT: B) abdominal tenderness; D) elevated maternal pulse rate; E) cloudy malodorous fluid Rationale: Possible signs of infection associated with premature rupture of membranes include elevation of maternal temperature and pulse rate, abdominal/uterine tenderness, fetal tachycardia over 160 bpm, elevated white blood cell count and C-reactive protein levels, and cloudy, foul-smelling amniotic fluid. Chapter 19

On a follow up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? A. sadness B. delusional beliefs C. feelings of anxiety D. insomnia

CORRECT: B) delusional beliefs Rationale: Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, delusional beliefs, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of anxiety, sadness, and insomnia are associated with postpartum depression.

After teaching the parents of a newborn with retinopathy of prematurity (ROP) about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A. "We'll make sure to administer eye drops each day for the next few weeks." B. "We can fix the problem with surgery." C. "Can we schedule follow-up vision screenings with the pediatric ophthalmologist now?" D. "I'm sure the baby will grow out of it.

CORRECT: C) "Can we schedule follow-up vision screening with the pediatric ophthalmologist now?" Rationale: Parents of a newborn with suspected retinopathy of prematurity (ROP) should schedule follow-up vision screenings with a pediatric ophthalmologist every 2 to 3 weeks, depending on the severity of the findings at the initial examination. Chapter 24

A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? A. prophylactic heparin administration B. warm compresses C. compression stockings D. early ambulation

CORRECT: D) Early ambulation Rationale: Although compression stockings and prophylactic heparin administration may be appropriate, the most cost-effective preventive method is early ambulation. It is also the easiest method. Warm compresses are used to treat superficial venous thrombosis. Chapter 22

A nurse is assessing a pregnant woman with gestational hypertension. Which finding would lead the nurse to suspect that the client has developed severe preeclampsia? A. urine protein 300 mg/24 hours B. blood pressure 150/96 mm Hg C. mild facial edema D. hyperreflexia

CORRECT: D) hyperreflexia Rationale: Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours, and hyperreflexia. Mild facial edema is associated with mild preeclampsia. Chapter 19

A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which measure would the nurse be least likely to include in this plan? A. Stimulate the infant with frequent handling. B. Give intermittent tube feedings. CorrectC. Administer oxygen using a oxygen hood. D. Keep the newborn in an open bassinet.

Correct C: administer oxygen using a oxygen hood. For the preterm infant experiencing respiratory distress, the nurse would expect to handle the newborn as little as possible to reduce oxygen requirements. Other appropriate interventions include keeping the infant warm preferably in a warmed isolette to conserve the baby's energy and prevent cold stress; administer oxygen using an oxygen hood; and provide energy through calories via intravenous dextrose or gavage or continuous tube feedings to prevent hypoglycemia. Chapter Number: 23

A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? Select all that apply. A. excessive sneezing B. overly vigorous sucking C. low whimpering cry D. tremors E. hypertonicity F. lethargy

Correct: A. excessive sneezing D. tremors E. hypertonicity Signs and symptoms of withdrawal, or neonatal abstinence syndrome, include: irritability, hypertonicity, excessive and often high-pitched crying, vomiting, diarrhea, feeding disturbances, respiratory distress, disturbed sleeping, excessive sneezing and yawning, nasal stuffiness, diaphoresis, fever, poor sucking, tremors, and seizures. Chapter Number: 20

A nurse is making a home visit to a postpartum client. Which finding would most likely lead the nurse to suspect that a woman is experiencing postpartum psychosis? A. delirium B. feelings of guilt C. sadness D. insomnia

Correct: A. delirium Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of guilt, sadness, and insomnia are associated with postpartum depression. Chapter Number: 22

A nurse is describing the risks associated with prolonged pregnancies as part of an inservice presentation. Which factor would the nurse be least likely to incorporate in the discussion as an underlying reason for problems in the fetus? A. increased amniotic fluid volume B. aging of the placenta C. cord compression D. meconium aspiration

Correct: A. increased amniotic fluid volume Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and cephalopelvic disproportion. All of these conditions predispose this fetus to birth trauma or a surgical birth. Uteroplacental insufficiency, meconium aspiration, and intrauterine infection contribute to the increased rate of perinatal deaths (Beacock, 2011). As the placenta ages, its perfusion decreases and it becomes less efficient at delivering oxygen and nutrients to the fetus. Amniotic fluid volume also begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased risk of cord compression because the cushioning effect offered by adequate fluid is no longer present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is released by the fetus in response to a hypoxic insult (Caughey & Butler, 2010). Chapter Number: 21

A nurse is conducting an assessment of a woman who has experienced PROM. Which finding would lead the nurse to suspect infection as the cause of a client's PROM? A. blue color on Nitrazine testing B. foul odor C. yellow-green fluid D. ferning

Correct: B. foul odor A foul odor of the amniotic fluid indicates infection. Yellow-green fluid would suggest meconium. A blue color on Nitrazine testing and ferning indicate the presence of amniotic fluid. Chapter Number: 19

A nurse is teaching a pregnant woman with preterm premature rupture of membranes who is about to be discharged home about caring for herself. Which statement by the woman indicates a need for additional teaching? A. "I need to call my doctor if my temperature increases." B. "I need to keep a close eye on how active my baby is each day." C. "It's okay for my husband and me to have sexual intercourse." D. "I can shower, but I shouldn't take a tub bath."

Correct: C. "It's okay for my husband and me to have sexual intercourse." The woman with preterm premature rupture of membranes should monitor her baby's activity by performing fetal kick counts daily, check her temperature and report any increases to the health care provider, not insert anything into her vagina or vaginal area, such as tampons or vaginal intercourse, and avoid sitting in a tub bath. Chapter Number: 19

A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk? A. low-birth-weight newborns B. large-for-gestational-age (LGA) newborns C. appropriate-for-gestational-age (AGA) newborns D. small-for-gestational-age (SGA) newborns

Correct: C. appropriate-for-gestational-age (AGA) newborns Appropriate-for-gestational-age (AGA) newborns are at the lowest risk for any problems. AGA characterizes approximately 80% of newborns and describes a newborn with a normal length, weight, head circumference, and body mass index. The other categories all have an increased risk of complications. Chapter Number: 23

When assessing several women for possible VBAC, which woman would the nurse identify as being the best candidate? A. one who has undergone a previous myomectomy B. one who has a history of a contracted pelvis C. one who had a previous cesarean birth via a low transverse incision D. one who has a vertical incision from a previous cesarean birth

Correct: C. one who had a previous cesarean birth via a low transverse incision VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis. Chapter Number: 21

A preterm newborn has received oxygen therapy during his 3-month stay in the NICU. As the newborn is prepared to be discharged home, the nurse anticipates a referral for which specialist? A. cardiologist B. neurologist C. ophthalmologist D. nephrologist

Correct: C. ophthalmologist Oxygen therapy has been implicated in the pathogenesis of retinopathy of prematurity (ROP). An ophthalmology consult for follow-up after discharge is essential for preterm infants who have received extensive oxygen. Although referrals to other specialists may be warranted depending on the newborn's status, there is no information to suggest that any would be needed. Chapter Number: 23

A nurse is assessing a preterm newborn. Which finding would alert the nurse to suspect that a preterm newborn is in pain? Selected Answer: A. oxygen saturation level of 94% B. bradycardia C. sudden high-pitched cry D. decreased muscle tone

Correct: C. sudden high-pitched cry The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone. Chapter Number: 23

A client is experiencing postpartum hemorrhage, and the nurse begins to massage her fundus. Which action would be most appropriate for the nurse to do when massaging the woman's fundus? Answers: A. Continue massaging the uterus for at least 5 minutes. B. Place the hands on the sides of the abdomen to grasp the uterus. C. Use an up-and-down motion to massage the uterus. D. Wait until the uterus is firm to express clots.

Correct: D. Wait until the uterus is firm to express clots. The uterus must be firm before attempts to express clots are made because application of firm pressure on an uncontracted uterus could lead to uterine inversion. One hand is placed on the fundus and the other hand is placed on the area above the symphysis pubis. Circular motions are used for massage. There is no specified amount of time for fundal massage. Uterine tissue responds quickly to touch, so it is important not to overmassage the fundus. Chapter Number: 22

A nurse is conducting a class for pregnant women with diabetes. Which factor would the nurse emphasize as being most important in helping to reduce the maternal/fetal/neonatal complications associated with pregnancy and diabetes? A. evaluation of retinopathy by an ophthalmologist B. stability of the woman's emotional and psychological status C. blood urea nitrogen level (BUN) within normal limits D. degree of glycemic control achieved during the pregnancy

Correct: D. degree of glycemic control achieved during the pregnancy Therapeutic management for the woman with diabetes focuses on tight glucose control, thereby minimizing the risks to the mother, fetus, and neonate. The woman's emotional and psychological status is highly variable and may or may not affect the pregnancy. Evaluating for long-term diabetic complications such as retinopathy or nephropathy, as evidenced by laboratory testing such as BUN levels, is an important aspect of preconception care to ensure that the mother enters the pregnancy in an optimal state. Chapter Number: 20

Assessment of a woman in labor who is experiencing hypertonic uterine dysfunction would reveal contractions that are: A. poor in quality. B. well coordinated. C. brief. D. erratic.

Correct: D. erratic Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix. Chapter Number: 21

A nurse is assessing a postpartum woman. Which finding would cause the nurse to be most concerned? A. leg pain on ambulation with mild ankle edema B. perineal pain with swelling along the episiotomy C. calf pain with dorsiflexion of the foot D. sharp, stabbing chest pain with shortness of breath

Correct: D. sharp, stabbing chest pain with shortness of breath Sharp, stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent. Chapter Number: 22

A woman with a history of systemic lupus erythematosus comes to the clinic for evaluation. The woman tells the nurse that she and her partner would like to have a baby but that they are afraid her lupus will be a problem. Which response would be most appropriate for the nurse to make? A. "Be sure that your lupus is stable or in remission for 6 months before getting pregnant." B. "If you get pregnant, we'll have to add quite a few medications to your normal treatment plan. C. "Your lupus will not have any effect on your pregnancy whatsoever." D. "It's probably not a good idea for you to get pregnant since you have lupus."

CorrectA. "Be sure that your lupus is stable or in remission for 6 months before getting pregnant." B. "If you get pregnant, we'll have to add quite a few medications to your normal treatment plan. C. "Your lupus will not have any effect on your pregnancy whatsoever." D. "It's probably not a good idea for you to get pregnant since you have lupus." If the woman is considering pregnancy, it is recommended that she postpone conception until the disease has been stable or in remission for 6 months. Active disease at time of conception and history of renal disease increase the likelihood of a poor pregnancy outcome (Cunningham, et al., 2014).In particular, if pregnancy is planned during periods of inactive or stable disease, the result often is giving birth to healthy full-term babies without increased risks of pregnancy complications. Women with SLE are at increased risk for adverse pregnancy outcomes and cardiovascular disease. A pregnancy with lupus is prone to complications, including flares of disease activity during pregnancy or in the postpartum period, preeclampsia, pregnancy loss, miscarriage, stillbirth, fetal growth restriction, and preterm birth. Treatment of SLE in pregnancy is generally limited to NSAIDs (e.g., ibuprofen), prednisone, and an antimalarial agent, hydroxychloroquine. During pregnancy in the woman with SLE, the goal is to keep drug therapy to a minimum. Chapter Number: 20

A woman with a history of systemic lupus erythematosus comes to the clinic for evaluation. The woman tells the nurse that she and her partner would like to have a baby but that they are afraid her lupus will be a problem. Which response would be most appropriate for the nurse to make? A. "Be sure that your lupus is stable or in remission for 6 months before getting pregnant." B. "Your lupus will not have any effect on your pregnancy whatsoever." C. "If you get pregnant, we'll have to add quite a few medications to your normal treatment plan. D. "It's probably not a good idea for you to get pregnant since you have lupus."

CorrectA. "Be sure that your lupus is stable or in remission for 6 months before getting pregnant." B. "Your lupus will not have any effect on your pregnancy whatsoever." C. "If you get pregnant, we'll have to add quite a few medications to your normal treatment plan. D. "It's probably not a good idea for you to get pregnant since you have lupus." Rationale: If the woman is considering pregnancy, it is recommended that she postpone conception until the disease has been stable or in remission for 6 months. Active disease at time of conception and history of renal disease increase the likelihood of a poor pregnancy outcome (Cunningham, et al., 2014).In particular, if pregnancy is planned during periods of inactive or stable disease, the result often is giving birth to healthy full-term babies without increased risks of pregnancy complications. Women with SLE are at increased risk for adverse pregnancy outcomes and cardiovascular disease. A pregnancy with lupus is prone to complications, including flares of disease activity during pregnancy or in the postpartum period, preeclampsia, pregnancy loss, miscarriage, stillbirth, fetal growth restriction, and preterm birth. Treatment of SLE in pregnancy is generally limited to NSAIDs (e.g., ibuprofen), prednisone, and an antimalarial agent, hydroxychloroquine. During pregnancy in the woman with SLE, the goal is to keep drug therapy to a minimum. Chapter 20

A nurse is teaching a woman about measures to prevent preterm labor in future pregnancies because the woman just experienced preterm labor with her most recent pregnancy. The nurse determines that the teaching was successful based on which statement by the woman? A. "I'll make sure to limit the amount of long distance traveling I do." B. "Stress isn't a problem that is related to preterm labor." C. "I'll need extra iron in my diet so I have a extra for the baby." D. "Separating pregnancies by about a year should be helpful."

CorrectA. "I'll make sure to limit the amount of long distance traveling I do." B. "Stress isn't a problem that is related to preterm labor." C. "I'll need extra iron in my diet so I have a extra for the baby." D. "Separating pregnancies by about a year should be helpful." Rationale: Appropriate measures to reduce the risk for preterm labor include: avoiding travel for long distances in cars, trains, planes or buses; achieving adequate iron store through balanced nutrition (excess iron is not necessary); waiting for at least 18 months between pregnancies, and using stress management techniques for stress. Chapter 21

A pregnant woman at 31-weeks' gestation calls the clinic and tells the nurse that she is having contractions sporadically. Which instructions would be most appropriate for the nurse to give the woman? Select all that apply. A. "Stop what you are doing and rest." B. "Drink 2 or 3 glasses of water." C. "Lie down on your back." D. "Try emptying your bladder." E. "Walk around the house for the next half hour."

CorrectA. "Stop what you are doing and rest." CorrectB. "Drink 2 or 3 glasses of water." C. "Lie down on your back." CorrectD. "Try emptying your bladder." E. "Walk around the house for the next half hour." Response Feedback: Appropriate instructions for the woman who may be experiencing preterm labor include having the client stop what she is doing and rest for an hour, empty her bladder, lie down on her left side, and drink two to three glasses of water." Chapter Number: 21 Page: 774

A woman is to undergo an amnioinfusion. Which statement would be most appropriate to include when teaching the woman about this procedure? A. "You'll need to stay in bed while you're having this procedure." B. "A suction cup is placed on your baby's head to help bring it out." C. "After the infusion, you'll be scheduled for a cesarean birth." D. "We'll give you an analgesic to help reduce the pain."

CorrectA. "You'll need to stay in bed while you're having this procedure." B. "A suction cup is placed on your baby's head to help bring it out." C. "After the infusion, you'll be scheduled for a cesarean birth." D. "We'll give you an analgesic to help reduce the pain." Rationale: An amnioinfusion involves the instillation of a volume of warmed, sterile normal saline or Ringer's lactate into the uterus via an intrauterine pressure catheter. The client must remain in bed during the procedure. The use of analgesia is unrelated to this procedure. A cesarean birth is necessary only if the FHR does not improve after the amnioinfusion. Application of a suction cup to the head of the fetus refers to a vacuum-assisted birth. Chapter 21

When developing the plan of care for a newborn with congenital condition, the nurse would include which measure to promote participation by the parents? A. Assist with decision-making process. B. Use verbal instructions primarily for explanations. C. Provide personal views about their decisions. D. Encourage them to refrain from showing emotions.

CorrectA. Assist with decision-making process. B. Use verbal instructions primarily for explanations. C. Provide personal views about their decisions. D. Encourage them to refrain from showing emotions. Rationale: To promote parental participation, the nurse should assist them with making decisions about treatment and support their decisions for the newborn's care. Imposing personal views about their decisions is inappropriate and undermines the nurse-client relationship. In addition, the nurse would assess their ability to cope with the diagnosis, encourage them to verbalize their feelings about the newborn's condition and treatment and educate them about the newborn's condition using written information and pictures to enhance understanding. Chapter 24

A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next? A. Notify the health care provider. B. Apply warm soaks to the area. C. Encourage the client to void. D. Massage the uterine fundus.

CorrectA. Notify the health care provider. B. Apply warm soaks to the area. C. Encourage the client to void. D. Massage the uterine fundus. Rationale: The client is experiencing postpartum hemorrhage secondary to a perineal hematoma. The nurse needs to notify the health care provider about these findings to prevent further hemorrhage. Applying warm soaks to the area would do nothing to control the bleeding. With a perineal hematoma, the uterus is firm, so massaging the uterus or encouraging the client to void would not be appropriate. Chapter 22

Which action would be most appropriate for the nurse to take when a newborn has an unexpected anomaly at birth? A. Show the newborn to the parents as soon as possible while explaining the defect. B. Tell the parents that the newborn must go to the nursery immediately. C. Remove the newborn from the birthing area immediately. D. Inform the parents that there is nothing wrong at the moment.

CorrectA. Show the newborn to the parents as soon as possible while explaining the defect. B. Tell the parents that the newborn must go to the nursery immediately. C. Remove the newborn from the birthing area immediately. D. Inform the parents that there is nothing wrong at the moment. Rationale: When an anomaly is identified at or after birth, parents need to be informed promptly and given a realistic appraisal of the severity of the condition, the prognosis, and treatment options so that they can participate in all decisions concerning their child. Removing the newborn from the area or telling them that the newborn needs to go to the nursery immediately is inappropriate and would only add to the parents' anxieties and fears. Telling them that nothing is wrong is inappropriate because it violates their right to know. Chapter 24

A nurse is explaining to the parents of a child with bladder exstrophy about the care their infant requires. Which measures would the nurse include in the explanation? Select all that apply. A. administering prescribed antibiotic therapy B. covering the area with a sterile, clear, nonadherent dressing C. irrigating the surface with sterile saline twice a day D. monitoring drainage through the suprapubic catheter E. preparing for surgical intervention in about 2 weeks

CorrectA. administering prescribed antibiotic therapy CorrectB. covering the area with a sterile, clear, nonadherent dressing C. irrigating the surface with sterile saline twice a day CorrectD. monitoring drainage through the suprapubic catheter E. preparing for surgical intervention in about 2 weeks Rationale: Care for an infant with bladder exstrophy includes covering the area with a sterile, clear, nonadherent dressing and irrigating the bladder surface with sterile saline after each diaper change to prevent infection, assisting with insertion and monitoring drainage from suprapubic catheter, administering prescribed antibiotic therapy, and preparing the parents and infant for surgery within 48 hours after birth. Chapter 24

A nurse is conducting a presentation for a group of pregnant women who are considered high-risk. After describing the complications that can occur in newborns, the nurse determines that the teaching was successful when the group identifies which newborn as having the lowest risk for problems? A. appropriate-for-gestational-age B. large-for-gestational-age C. small-for-gestational-age D. low-birthweight

CorrectA. appropriate-for-gestational-age B. large-for-gestational-age C. small-for-gestational-age D. low-birthweight Appropriate-for-gestational-age newborns are at the lowest risk for any problems. The other categories all have an increased risk of complications. Chapter Number: 23

It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time? A. at 28 weeks' gestation and again within 72 hours after delivery B. 24 hours before delivery and 24 hours after delivery C. at 32 weeks' gestation and immediately before discharge D. in the first trimester and within 2 hours of delivery

CorrectA. at 28 weeks' gestation and again within 72 hours after delivery B. 24 hours before delivery and 24 hours after delivery C. at 32 weeks' gestation and immediately before discharge D. in the first trimester and within 2 hours of delivery Rationale: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after delivery. Chapter 19

The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse determines that the women understood the description when they identify the condition as postpartum: A. blues. B. bipolar disorder. C. depression. D. psychosis.

CorrectA. blues. B. bipolar disorder. C. depression. D. psychosis. Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with childbirth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania. Chapter Number: 22

The nurse is assessing a preterm newborn's fluid and hydration status. Which finding would alert the nurse to possible over hydration? A. bulging fontanels B. decreased urine output C. tachypnea D. elevated temperature

CorrectA. bulging fontanels B. decreased urine output C. tachypnea D. elevated temperature Bulging fontanels in a preterm newborn suggest overhydration. Sunken fontanels, decreased urine output, and elevated temperature would suggest dehydration. Chapter Number: 23

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which factor? A. Deficiency of surfactant B. smaller respiratory passages C. inability to clear fluids D. immature respiratory control center

CorrectA. deficiency of surfactant B. smaller respiratory passages C. inability to clear fluids D. immature respiratory control center A preterm newborn is at increased risk for respiratory distress syndrome (RDS) most commonly because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages lead to an increased risk for obstruction. Chapter Number: 23

A pregnant client has received dinoprostone. Following administration of this medication, the nurse assesses the client and determines that the client is experiencing an adverse effect of the medication based on which client report? Select all that apply. A. diarrhea B. hypotension C. headache D. nausea E. tachycardia

CorrectA. diarrhea B. hypotension CorrectC. headache CorrectD. nausea E. tachycardia rationale: Adverse effects associated with dinoprostone include headache, nauseas and vomiting, and diarrhea. Tachycardia and hypotension are not associated with this drug. Chapter 21

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which characteristic would the nurse correlate with this gestational age variation? A. difficulty in arousing to a quiet alert state B. wasted appearance of extremities C. strong, brisk motor skills D. birthweight of 7 lb 14 oz (3,572 g)

CorrectA. difficulty in arousing to a quiet alert state B. wasted appearance of extremities C. strong, brisk motor skills D. birthweight of 7 lb 14 oz (3,572 g) Rationale: LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz (3,997 g) at term. Chapter 23

While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios based on which factor? Select all that apply. A. difficulty obtaining fetal heart rate B. history of diabetes C. reports shortness of breath D. identifiable fetal parts on abdominal palpation E. fundal height below that for expected gestational age

CorrectA. difficulty obtaining fetal heart rate CorrectB. history of diabetes CorrectC. reports shortness of breath D. identifiable fetal parts on abdominal palpation E. fundal height below that for expected gestational age Rationale: Factors such as maternal diabetes or multiple gestations place the woman at risk for hydramnios. In addition, there is a discrepancy between fundal height and gestational age, such that a rapid growth of the uterus is noted. Shortness of breath may result from overstretching of the uterus due to the increased amount of amniotic fluid. Often, fetal parts are difficult to palpate and fetal heart rate is difficult to obtain because of the excess fluid present. Chapter 19

The nurse is assessing the newborn of a mother who had gestational diabetes. Which findings would the nurse expect? Select all that apply. A. distended upper abdomen B. long slender neck C. pale skin color D. buffalo hump E. excessive subcutaneous fat

CorrectA. distended upper abdomen B. long slender neck C. pale skin color CorrectD. buffalo hump CorrectE. excessive subcutaneous fat Rationale: Infants of diabetic mothers exhibit full rosy cheeks with a ruddy skin color, short neck, buffalo hump over the nape of the neck, massive shoulders, distended upper abdomen, and excessive subcutaneous fat tissue. Chapter 24

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply. A. dysuria B. malodorous vaginal discharge C. constipation D. four to five contractions in 1 hour E. dull low backache

CorrectA. dysuria CorrectB. malodorous vaginal discharge C. constipation D. four to five contractions in 1 hour CorrectE. dull low backache Response Feedback: Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour. Chapter Number: 21 Page: 772

A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding? A. elevated liver enzymes B. disseminated intravascular coagulopathy (DIC) C. elevated platelet count D. hyperglycemia

CorrectA. elevated liver enzymes B. disseminated intravascular coagulopathy (DIC) C. elevated platelet count D. hyperglycemia HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia is not a part of this syndrome. HELLP may increase the woman's risk for DIC. Chapter Number: 19

A nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion. The nurse determines that the teaching was successful when the group identifies which condition as the most common cause of first trimester abortions? A. fetal genetic abnormalities B. uterine fibroids C. maternal disease D. cervical insufficiency

CorrectA. fetal genetic abnormalities B. uterine fibroids C. maternal disease D. cervical insufficiency Rationale: The causes of spontaneous abortion are varied and often unknown. The most common cause for first-trimester abortions is fetal genetic abnormalities, usually unrelated to the mother. Chromosomal abnormalities are more likely causes in first trimester, and maternal disease is more likely in the second trimester. Those occurring during the second trimester are more likely related to maternal conditions, such as cervical insufficiency, congenital, or acquired anomaly of the uterine cavity (uterine septum or fibroids), hypothyroidism, diabetes mellitus, chronic nephritis, use of crack cocaine, inherited and acquired thrombophilias, lupus, polycystic ovary syndrome, severe hypertension, and acute infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis. Chapter 19

A newborn was diagnosed with a congenital heart defect and will undergo surgery at a later time. The nurse is teaching the parents about signs and symptoms that need to be reported. The nurse determines that the parents have understood the instructions when they state that they will report which signs? Select all that apply. CorrectA. fever CorrectB. increased respiratory rate C. absence of edema CorrectD. weight loss E. pale skin

CorrectA. fever CorrectB. increased respiratory rate C. absence of edema CorrectD. weight loss E. pale skin Signs and symptoms that need to be reported include weight loss, poor feeding, cyanosis, breathing difficulties, irritability, increased respiratory rate, and fever. Chapter Number: 24

A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: A. helps support the lower uterine segment. B. aids in expressing accumulated clots. C. prevents uterine muscle fatigue. D. determines that the procedure is effective.

CorrectA. helps support the lower uterine segment. B. aids in expressing accumulated clots. C. prevents uterine muscle fatigue. D. determines that the procedure is effective. The nurse places the nondominant hand on the area above the symphysis pubis to help support the lower uterine segment. The hand, usually the dominant hand that is placed on the fundus, helps to determine uterine firmness (and thus the effectiveness of the massage). Applying gentle downward pressure on the fundus helps to express clots. Overmassaging the uterus leads to muscle fatigue. Chapter Number: 22

A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select all that apply. A. indomethacin B. nifedipine C. misoprostol D. magnesium sulfate E. dinoprostone

CorrectA. indomethacin CorrectB. nifedipine C. misoprostol CorrectD. magnesium sulfate E. dinoprostone Rationale: Medications most commonly used for tocolysis include magnesium sulfate (which reduces the muscle's ability to contract), indomethacin (a prostaglandin synthetase inhibitor), and nifedipine (a calcium channel blocker). These drugs are used "off label": this means they are effective for this purpose but have not been officially tested and developed for this purpose by the FDA. Dinoprostone and misoprostol are used to ripen the cervix. Chapter 21

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn? A. infection B. hypovolemia C. trauma D. hemorrhage

CorrectA. infection B. hypovolemia C. trauma D. hemorrhage Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the prolonged premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes removes the barrier of amniotic fluid, so bacteria can ascend. Chapter Number: 22

After presenting an in-service presentation on measures to prevent postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which measure to prevent postpartum hemorrhage due to retained placental fragments? A. inspecting the placenta after delivery for intactness B. applying pressure to the umbilical cord to remove the placenta C. administering broad-spectrum antibiotics D. manually removing the placenta at delivery

CorrectA. inspecting the placenta after delivery for intactness B. applying pressure to the umbilical cord to remove the placenta C. administering broad-spectrum antibiotics D. manually removing the placenta at delivery Response Feedback: After birth, a thorough inspection of the placenta is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage. Chapter Number: 22 Page: 801

A newborn is diagnosed with meconium aspiration syndrome. When assessing this newborn, the nurse would expect which findings? Select all that apply. A. intercostal retractions B. coarse crackles on auscultation C. high blood pH level D. prolonged tachypnea E. pigeon chest

CorrectA. intercostal retractions CorrectB. coarse crackles on auscultation C. high blood pH level CorrectD. prolonged tachypnea E. pigeon chest Rationale: Assessment findings associated with meconium aspiration syndrome include barrel-shaped chest with an increased anterior-posterior (AP) chest diameter (similar to that found in a client with chronic obstructive pulmonary disease), prolonged tachypnea, progression from mild to severe respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis. Coarse crackles and rhonchi are noted on lung auscultation. Chapter 24

A pregnant client whose diabetes has been poorly controlled throughout her pregnancy is in labor. The nurse would assess the neonate closely at birth for which condition? A. macrosomia B. hypobilirubinemia C. low birthweight D. hyperglycemia

CorrectA. macrosomia B. hypobilirubinemia C. low birthweight D. hyperglycemia Rationale: Poorly controlled diabetes during pregnancy can result in macrosomia due to hyperinsulinemia stimulated by fetal hyperglycemia. Typically the neonate is hypoglycemic due to the ongoing hyperinsulinemia that occurs after the placenta is removed. Infants of diabetic women typically are large and are at risk for hyperbilirubinemia due to excessive red blood cell breakdown. Chapter 20

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply. A. malodorous vaginal discharge B. four to five contractions in 1 hour C. dysuria D. constipation E. dull low backache

CorrectA. malodorous vaginal discharge B. four to five contractions in 1 hour CorrectC. dysuria D. constipation CorrectE. dull low backache Response Feedback: Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour. Chapter Number: 21 Page: 772

A nurse is teaching a group of pregnant women about the adverse effects of substances on the fetus. The nurse determines that additional teaching is needed when the group identifies which substance as being teratogenic? A. marijuana B. nicotine C. cocaine D. alcohol

CorrectA. marijuana B. nicotine C. cocaine D. alcohol Rationale: Marijuana has not been shown to have teratogenic effects on the fetus. Alcohol, nicotine, and cocaine do affect the fetus. Chapter 24

A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding? A. moderate lochia serosa B. fever C. nonpalpable fundus D. bruising on arms and legs

CorrectA. moderate lochia serosa B. fever C. nonpalpable fundus D. bruising on arms and legs Rationale: Subinvolution is usually identified at the woman's postpartum examination 4 to 6 weeks after birth. The clinical picture includes a postpartum fundal height that is higher than expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within a few weeks. Normally, at 4 to 6 weeks, lochia alba or no lochia would be present and the fundus would not be palpable. Thus evidence of lochia serosa suggests subinvolution. Bruising would suggest a coagulopathy. Fever would suggest an infection. Chapter 22

A nurse is conducting an in-service program for a group of labor and birth unit nurses about cesarean birth. The group demonstrates understanding of the information when they identify which condition as an appropriate indication? Select all that apply. A. placenta previa B. prolonged labor C. previous cesarean birth D. active genital herpes infection E. fetal distress

CorrectA. placenta previa B. prolonged labor CorrectC. previous cesarean birth CorrectD. active genital herpes infection CorrectE. fetal distress The leading indications for cesarean birth are previous cesarean birth, breech presentation, dystocia, and fetal distress. Examples of specific indications include active genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality (placenta previa or abruptio placentae), previous classic uterine incision or scar, gestational hypertension, diabetes, positive HIV status, and dystocia. Fetal indications include malpresentation (nonvertex presentation), congenital anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress. Chapter 21

A newborn is diagnosed with meconium aspiration syndrome. When assessing this newborn, the nurse would expect which findings? Select all that apply. A. prolonged tachypnea B. intercostal retractions C. high blood pH level D. pigeon chest E. coarse crackles on auscultation

CorrectA. prolonged tachypnea CorrectB. intercostal retractions C. high blood pH level D. pigeon chest CorrectE. coarse crackles on auscultation Assessment findings associated with meconium aspiration syndrome include barrel-shaped chest with an increased anterior-posterior (AP) chest diameter (similar to that found in a client with chronic obstructive pulmonary disease), prolonged tachypnea, progression from mild to severe respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis. Coarse crackles and rhonchi are noted on lung auscultation. Chapter Number: 24

A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? A. sharp stabbing chest pain with shortness of breath B. leg pain on ambulation with mild ankle edema C. perineal pain with swelling along the episiotomy D. calf pain with dorsiflexion of the foot

CorrectA. sharp stabbing chest pain with shortness of breath B. leg pain on ambulation with mild ankle edema C. perineal pain with swelling along the episiotomy D. calf pain with dorsiflexion of the foot Response Feedback: Sharp stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent. Chapter Number: 22 Page: 810

A nurse is reviewing the medical record of a pregnant client. The nurse suspects that the client may be at risk for dystocia based on which factor? Select all that apply. A. short maternal stature B. multiparity C. maternal age over 35 D. plan for pudendal block anesthetic use E. breech fetal presentation

CorrectA. short maternal stature B. multiparity CorrectC. maternal age over 35 D. plan for pudendal block anesthetic use CorrectE. breech fetal presentation Response Feedback: According to American College of Obstetrics and Gynecology, factors associated with an increased risk for dystocia include epidural analgesia, excessive analgesia, multiple gestation, hydramnios, maternal exhaustion, ineffective maternal pushing technique, occiput posterior position, longer first stage of labor, nulliparity, short maternal stature (less than 5 feet tall), fetal birth weight (more than 8.8 lb 3.9 kg), shoulder dystocia, abnormal fetal presentation or position (breech), fetal anomalies (hydrocephalus), maternal age older than 35 years, high caffeine intake, overweight, gestational age more than 41 weeks, chorioamnionitis, ineffective uterine contractions, and high fetal station at complete cervical dilation. Chapter Number: 21 Page: 757

A woman with diabetes is considering becoming pregnant. She asks the nurse whether she will be able to take oral hypoglycemics when she is pregnant. The nurse's response is based on the understanding that oral hypoglycemics: A. show promising results, but more studies are needed to confirm their degree of safety. B. are usually suggested primarily for women who develop gestational diabetes. C. can be taken until the degeneration of the placenta occurs. D. can be used as long as they control serum glucose levels.

CorrectA. show promising results, but more studies are needed to confirm their degree of safety. B. are usually suggested primarily for women who develop gestational diabetes. C. can be taken until the degeneration of the placenta occurs. D. can be used as long as they control serum glucose levels. Rationale: Recent studies have examined the use of oral hypoglycemic medications in pregnancy with much success. Several studies have used glyburide with promising results. Many health care providers are using glyburide and metformin as an alternative to insulin therapy because they do not cross the placenta and therefore do not cause fetal/neonatal hypoglycemia. Some oral hypoglycemic medications are considered safe and may be used if nutrition and exercise are not adequate alone. Maternal and newborn outcomes are similar to those seen in women who are treated with insulin. Oral hypoglycemic agents, however, must be further investigated to determine their safety with confidence and provide better treatment options for diabetes in pregnancy. Currently, there is a growing acceptance of glyburide use as a primary therapy for gestational diabetes. Glyburide and metformin have also been found to be safe, effective, and economical for the treatment of gestational diabetes, although neither drug has been approved by the FDA for use in pregnancy. Chapter 20

The nurse is assessing a newborn and suspects that the newborn was exposed to drugs in utero because the newborn is exhibiting signs of neonatal abstinence syndrome. Which findings would the nurse expect to assess? Select all that apply. A. shrill, high-pitched cry B. hypothermia C. tremors D. regurgitation E. frequent sneezing F. diminished sucking

CorrectA. shrill, high-pitched cry B. hypothermia CorrectC. tremors CorrectD. regurgitation CorrectE. frequent sneezing F. diminished sucking Rationale: Signs and symptoms of neonatal abstinence syndrome include tremors, frantic sucking, regurgitation or projectile vomiting, shrill high-pitched cry, fever, and frequent sneezing. Chapter 24

A nurse is reviewing an article about preterm premature rupture of membranes. Which factors would the nurse expect to find placing a woman at high risk for this condition? Select all that apply. A. smoking B. urinary tract infection C. high body mass index D. single gestations E. low socioeconomic status

CorrectA. smoking CorrectB. urinary tract infection C. high body mass index D. single gestations CorrectE. low socioeconomic status Rationale: High-risk factors associated with preterm PROM include low socioeconomic status, multiple gestation, low body mass index, tobacco use, preterm labor history, placenta previa, abruptio placenta, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis. Chapter 19

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which measures would the nurse include? Select all that apply. A. using kangaroo care B. providing nonnutritive sucking C. positioning newborn in extension D. clustering care to promote rest E. loosely covering the newborn with blankets

CorrectA. using kangaroo care CorrectB. providing nonnutritive sucking C. positioning newborn in extension CorrectD. clustering care to promote rest E. loosely covering the newborn with blankets Rationale: The nurse would focus the plan of care on developmental care, which includes clustering care to promote rest and conserve energy, using flexed positioning to simulate in utero positioning, using kangaroo care to promote skin to skin sensations, swaddling with a blanket to maintain the flexed position, and providing nonnutritive sucking. Chapter: 23

The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which measures would the nurse most likely include in this teaching plan? Select all that apply. A. washing hands before and after perineal care B. handling perineal pads by the edges C. directing peribottle to flow from back to front D. taking the prescribed antibiotic until it is finished E. checking temperature once a week

CorrectA. washing hands before and after perineal care CorrectB. handling perineal pads by the edges C. directing peribottle to flow from back to front CorrectD. taking the prescribed antibiotic until it is finished E. checking temperature once a week Teaching should address taking the prescribed antibiotic until finished to ensure complete eradication of the infection; checking temperature daily and notifying the practitioner if it is above 100.4° F; washing hands thoroughly before and after eating, using the bathroom, touching the perineal area or providing newborn care; handling perineal pads by the edges and avoiding touching the inner aspect of the pad that is against the body; and directing peribottle so that it flows from front to back. Chapter Number: 22

When assessing a pregnant woman with heart disease throughout the antepartal period, the nurse would be especially alert for signs and symptoms of cardiac decompensation at which time? A. 24 to 28 weeks' gestation B. 28 to 32 weeks' gestation C. 16 to 20 weeks' gestation D. 20 to 24 weeks' gestation

CorrectB. 28 to 32 weeks' gestation Response Feedback: A pregnant woman with heart disease is most vulnerable for cardiac decompensation from 28 to 32 weeks' gestation. Chapter Number: 20

A nurse is reviewing a journal article about newborn pain prevention and management. Which information would the nurse most likely find discussed in the article? A. Newborns may be less sensitive to pain than adult. B. Pain is frequently mistaken for irritability or agitation. C. Newborns rarely experience pain with procedures. D. Newborn pain is frequently recognized and treated.

CorrectB. Pain is frequently mistaken for irritability or agitation. Response Feedback: Assessment of pain in the newborn remains a contentious and vexing problem. According to an international consortium, principles of newborn pain prevention and management include the following: newborn pain frequently goes unrecognized and under treated; newborns experience pain, and analgesics should be given; a procedure considered painful for an adult should also be considered painful for a newborn; newborns may be more sensitive to pain than adults; and pain behavior is frequently mistaken for irritability and agitation. Chapter Number: 23 Page: 853