Combo with "Postpartum Care Part 2 from NCLEX-RN Maternal-Neonatal Nursing" and 8 others
A postpartum primiparous client is having difficulty breastfeeding her infant. The infant latches on to the breast but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breastfeeding when she states:
"As long as some of my nipple is in the baby's mouth, the baby will receive enough milk."
A client who is positive for HIV tells a nurse she would like to breast-feed. Which is the best response by the nurse?
"Breast milk can transmit HIV to the baby."
A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which of the following responses is most appropriate to address the mother's concerns regarding her neonate's breast-feeding behavior?
"Breast milk is ideal for your baby, so his stomach will digest it quickly, which requires more feedings."
A diabetic postpartum client plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when she states:
"Breastfeeding will assist in lowering maternal blood glucose."
The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?
"Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."
After a vaginal delivery, a postpartum client complains of perineal discomfort when sitting. To promote comfort, the nurse should provide which instruction?
"Contract your buttocks before sitting or rising."
A client in active labor has severe second-degree burns on her buttocks. When questioned about the burns, the client replies, "I was trying to use that hot water thing to help my hemorrhoids." What should the nurse say in response to this client?
"Does your doctor know about the burns?"
A 24-year-old multigravida client who had an uncomplicated, spontaneous vaginal delivery 7 hours ago is uninterested in her baby and wants to sleep. The student nurse assigned to care for the client is concerned and tells the licensed practical nurse (LPN) who's also assigned to her care. Which response by the LPN is most effective in educating the student nurse?
"Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience."
A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory tract infection following childbirth. The nurse determines the client understands principles of infection control to follow when the client says:
"I must practice frequent hand washing."
A nurse is teaching a breastfeeding primiparous client how to prevent sore nipples. Which client statement indicates the need for further instruction?
"I should breastfeed for only 3 to 4 minutes at a time until my milk flow is established."
After a vaginal birth, a postpartum client complains of perineal discomfort when sitting. A nurse provides teaching on how to promote comfort. Which statement by the client indicates an understanding of how to promote comfort?
"I should contract my buttocks before sitting or rising."
After being treated with heparin therapy for thrombophlebitis, a multiparous client who gave birth 4 days ago is to be discharged on oral warfarin. After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching?
"I should use a soft toothbrush to brush my teeth."
A mother is concerned that her neonate, who was delivered without complications at 38 weeks, isn't eating enough and will lose too much weight. The mother states, "He only breast-feeds for about 3 minutes on one side." Which instruction should the nurse provide to this mother?
"I understand your concern, but he has stored nutrients before birth just for this reason."
Which statement by a client shows she understands how to prevent breast engorgement while breastfeeding?
"I will breastfeed every 1 to 3 hours."
A postpartum client is ready for discharge. Which client statement reflects an understanding of the teaching session?
"I will call my physician if I notice redness, warmth, and pain in my breasts."
When giving a postpartum client self-care instructions, a nurse instructs her to report heavy or excessive bleeding. Which statement by the client indicates that she understands the nurse's instructions?
"I will call the doctor if I saturate a pad in 1 hour or less."
Which client statement should alert the nurse to a potential problem in a breastfeeding primiparous client?
"I will limit my fluid intake."
A nurse is about to give a client with type 2 diabetes mellitus her insulin before breakfast on her first day postpartum. Which statement by the client indicates an understanding of insulin requirements immediately postpartum?
"I will need less insulin now than before I was pregnant."
Which statement indicates to a nurse that a client needs further instruction on the use of anticoagulant therapy for deep vein thrombosis?
"I will take aspirin for headaches."
A client tells a nurse that she's going to breast-feed her neonate, but she isn't sure what she should eat. Which client statement requires further teaching?
"I'll take all the same medications I was taking before my pregnancy."
During a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
"I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.
The nurse demonstrates bathing of a neonate to a primiparous client. Which statement by the client indicates understanding?
"I'm going to bathe the baby in the kitchen because it's nice and warm there."
The nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching?
"If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."
A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in her teaching?
"If you have excessive vaginal bleeding, massage your fundus and call the physician."
A postpartum client who is bottle-feeding her neonate asks the nurse when she can expect her menstrual period to return. How should the nurse respond?
"In 7 to 9 weeks"
On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which response by the nurse would be appropriate?
"It isn't unusual to have those feelings after delivery."
A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician prescribes bethanechol (Urecholine), 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond?
"It stimulates the smooth muscle of the bladder."
A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate?
"It will probably be 6 to 10 weeks before it starts again."
The night before discharge, a client expresses guilt that she'll have to return to work in 3 weeks and leave her infant with a nanny. The client asks the nurse for an opinion about using a nanny. What should the nurse say first?
"It's difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you're gone."
A new mother who's breast-feeding asks how quickly she can expect to lose the 40 lb she gained during pregnancy. Which response by the nurse is best?
"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."
After delivering her second baby, the client tells the nurse that she wants to breast-feed this baby. She indicates that she was unsuccessful at breast-feeding her first child and that she bottle-fed after 3 days of trying to nurse. Which of the following responses would best support this client's breast-feeding efforts?
"It's important to room-in with your newborn so that you can respond to her nursing cues."
The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for the human immunodeficiency virus (HIV). The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse?
"It's inappropriate to refuse this assignment; all clients should be treated equally."
The mother of a 3-day-old, breast-fed infant expresses concern that her infant has had two recent diapers that contained a lot of loose, yellowish stool. Which explanation by the nurse is best?
"It's normal for breast-fed infants to pass three or more loose, yellow stools per day."
During a home visit to a primiparous client who gave vaginal birth 14 days ago, the client says, "I've been crying a lot the last few days. I just feel so awful. I am a rotten mother. I just don't have any energy. Plus, my husband just got laid off from his job." The nurse observes that the client's appearance is disheveled. Which of the following would be the nurse's best response?
"It's not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your doctor."
A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate?
"Leave the diaphragm in place for at least 6 hours after intercourse."
The nurse is teaching a client how to use a diaphragm. Which instruction should the nurse provide?
"Leave the diaphragm in place for at least 6 hours after intercourse."
The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which of the following client statements indicates that this teaching has been effective?
"My menstrual flow should resume in approximately 6 to 10 weeks."
A parent asks the nurse about the practice of adding rice cereal at age 3 months to a bedtime bottle to "help the baby sleep through the night." Which response accurately addresses the parent's concern?
"Nighttime feedings provide the infant with adequate fluid, and are typically needed until at least age 4 months."
A woman who is Rh-negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) Immune Globulin (RhoGAM). The nurse determines that the client understands the purpose of RhoGAM when she states:
"RhoGAM will prevent antibody formation in my blood."
A client who is 1-day postpartum following birth of a viable neonate asks the nurse about resuming sexual activity. After giving instructions, the nurse determines that the client understands the instructions when she says:
"Sexual intercourse may be resumed about 3 to 4 weeks postpartum."
A primiparous client who gave birth 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate?
"Squeeze your buttock muscles together before sitting down."
A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?
"The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment."
The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?
"The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment."
A client in the early stages of labor asks the nurse whether it's really necessary for her to purchase a car seat, noting that they're very expensive. Which response by the nurse is best?
"The only way to safely transport your baby in a car is to have him restrained securely in a car seat."
A nurse is teaching a postpartum client how to perform Kegel exercises. Which client statement indicates an understanding of the purpose of these exercises?
"These exercises help to strengthen the perineal muscles."
While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate?
"They usually fade to a silvery-white color over a period of time."
A client is 2 days postpartum and is talking with her nurse about the bleeding she's having, asking, "Will it always be so heavy?" Which statement by the nurse would be the most accurate?
"This is rochia rubra and will last 3-4 days."
Accompanied by her husband, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first?
"What is your expected due date?"
Which of the following client statements indicates effective teaching about burping a breastfed neonate?
"When I switch to the other breast, I'll burp the baby."
The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What is the best response by the nurse?
"You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."
A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" The nurse should tell the client:
"You can continue to breastfeed as long as you want to do so."
The nurse is reviewing discharge instructions with a postpartum breastfeeding client who is going home. She has chosen medroxyprogesterone as birth control. Which statement by the client identifies that she needs further instruction concerning birth control?
"You will give me my first medroxyprogesterone shot before I leave today."
(Select all that apply) A nurse is assigned to assist with the admission of a client who is in labor. Which of the following actions are appropriate?
(1) Asking about the estimated date of delivery (EDD), (3) Taking maternal and fetal vital signs, (6) Asking about the amount of time between contractions
(SELECT ALL THAT APPLY) The nurse is assisting in the delivery room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate delivery. Which interventions should the nurse perform when caring for the client after this procedure?
(1) Check the episiotomy repair site., (2) Apply ice to the perineum, (4) Administer pain medication, as prescribed., (5) Explain perineal care to the client when she is able to focus on the instructions.
(SELECT ALL THAT APPLY) The nurse must administer erythromycin ophthalmic ointment 0.5% to a neonate born 30 minutes ago. How should the nurse proceed?
(1) Clean the eyes before administration (2) Put on gloves.(4) Open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. (5) Spread the ointment from the inner canthus of the eye to the outer canthus. (6) Wipe excess ointment from the eyes after waiting 1 minute.
(SELECT ALL THAT APPLY) The nurse is assisting in monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be alert to which of the following maternal adverse reactions?
(1) Hypertension, (4) Fluid Overload, (5) Uterine Tetany
(SELECT ALL THAT APPLY) Which conditions are contraindications to epidural blocks?
(1) Infection at the injection site, (2) Allergy to the anesthetic drug, (4) Anticoagulant therapy, (5) Bleeding disorder
(SELECT ALL THAT APPLY) The nurse is collecting data on client who is 1 day postpartum. The nurse expects which normal findings?
(1) Lochia Rubra, (4) Heart rate of 50 to 70 beats/minute
(SELECT ALL THAT APPLY) A client receives an epidural block for pain relief during labor. Which interventions by the nurse are important when caring for a client with an epidural block?
(1) Make sure oxygen is available., (3) Monitor vital signs frequently., (5) Monitor fetal heart rate and contractions closely.
(SELECT ALL THAT APPLY) A primigravida experiences spontaneous rupture of the membranes. What should the nurse do?
(1) Perform a nitrazine test to confirm that the membranes are ruptured, (2) Monitor fetal heart rate and pattern., (3) Assess maternal temperature.
(SELECT ALL THAT APPLY) The nurse observes several interactions between a mother and her new son. Which of the following behaviors by the mother would the nurse identify as evidence of mother-neonate attachment?
(1) Talks and coos to her son, (2) Cuddles her son close to her
(SELECT ALL THAT APPLY) The nurse is caring for a client who has been diagnosed with abruptio placenta. What signs and symptoms of abruptio placenta should the nurse expect to find when she is collecting data on this client?
(1) Vaginal bleeding, (3) Uterine tenderness on palpation, (6) Abnormal fetal heart tones
(SELECT ALL THAT APPLY) On examining a client who gave birth 3 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which of the following actions should the nurse take?
(2) Assess the client's vital signs., (3) Palpate the client's fundus.
(SELECT ALL THAT APPLY) The nurse is instructing the client on breast-feeding. Which instructions should she include to help the mother prevent mastitis?
(2) Change the breast pads frequently., (3) Expose your nipples to air part of each day., (4) Wash your hands before handling your breast and breast-feeding., (6) Release the baby's grasp on the nipple before removing him from the breast.
(SELECT ALL THAT APPLY) A client in labor is given meperidine (Demerol), 25 mg I.V., for labor pain. The nurse should monitor the client for which adverse effects of the drug?
(2) Nausea & Vomiting, (3) Respiratory Depression, (5) Tachycardia
(SELECT ALL THAT APPLY) The nurse is assisting in developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis Acute pain related to perineal sutures?
(3) Administer sitz baths three to four times per day., (4) Encourage the client to do Kegel exercises.
(SELECT ALL THAT APPLY) The nurse is assisting in caring for a client who has just given birth to a neonate through vaginal delivery. The nurse is monitoring for signs of placental separation. Which of the following signs indicate that the placenta has separated?
(3) Sudden gush of vaginal blood, (4) Change in shape of the uterus, (5) Lengthening of the umbilical cord
The physician orders digoxin 0.1 mg orally every morning for a 6-month-old infant with heart failure. Digoxin is available in a 400 mcg/ml concentration. How many milliliters of digoxin should the nurse give?
0.25
The physician prescribes phytonadione (AquaMEPHYTON), 0.5 mg I.M., for a neonate born 30 minutes ago. The nurse has a solution containing 2 mg/ml. How many milliliters of solution should the nurse administer to achieve this dose?
0.25
After pitocin is administed, how often is it increased determining on dilation and effacement?
1-2mu per 15 min 20 mu max. 30 mu max with physician orders
A 10-month-old infant with recurrent otitis media (middle ear inflammation) is brought to the clinic for evaluation. To help determine the cause of the infant's condition, the nurse should ask the parents:
1. "Does water ever get into the baby's ears during shampooing?"
After the birth of her first neonate, a mother asks the nurse about the reddened areas ("stork bites") at the nape of the neonate's neck. How should the nurse respond?
1. "They're normal and will disappear as the baby's skin thickens."
The nurse is teaching parents about the nutritional needs of their full-term infant, age 2 months, who's breast-feeding. Which response shows that the parents understand their infant's dietary needs?
1. "We won't start any solid foods now."
A mother brings her 8-month-old son to the pediatrician's office. When the nurse approaches to measure the child's vital signs, he clings to his mother tightly and starts to cry. The mother says, "He used to smile at everyone. I don't know why he's acting this way." Which response by the nurse would help the mother understand her child's behavior?
1. "Your baby's behavior indicates stranger anxiety, which is common at his age."
A 5-month-old infant with an upper respiratory infection is brought to the clinic. The mother reports that the infant weighed 7 lb (3.2 kg) at birth. Based on the nurse's knowledge of infant weight gain, which current weight would be within the normal range for this infant?
1. 14 lb (6.4 kg)
The charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse?
1. A stable 6-month-old infant with pneumonia
Parents bring their infant to the clinic seeking treatment for vomiting and diarrhea that has lasted for 2 days. While collecting data on the infant, the nurse detects dry mucous membranes and lethargy. What other finding suggests deficient fluid volume?
1. A sunken fontanel
Which action should the nurse include in the plan of care for a 2-month-old infant with heart failure?
1. Allow the infant to rest before feeding.
The nurse is caring for a 1-month-old infant who fell from the changing table during a diaper change. Which signs and symptoms of increased intracranial pressure (ICP) is the nurse likely to assess in a 1-month-old infant?
1. Bulging fontanels, 4. High-pitched cry, 6. Irritability
A baby boy has just had surgery to repair his cleft lip. Which nursing intervention is the most important during the immediate postoperative period?
1. Clean the suture line carefully with a sterile solution after every feeding.
When developing a postoperative plan of care for an infant scheduled for cleft lip repair, the nurse should assign highest priority to which intervention?
1. Comforting the child as quickly as possible
A hospitalized infant, age 10 months, begins to choke while eating and quickly becomes unconscious. A foreign object isn't visible in the infant's airway, but respirations are absent and the pulse is 50 beats/minute and thready. The nurse attempts rescue breathing, but the ventilations are unsuccessful. What should the nurse do next?
1. Deliver five back blows.
Which behavior is the most reliable pain indicator in an infant?
1. Facial expression
At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase (Pancrease). At a follow-up visit, which finding suggests the need for further teaching?
1. Fatty stools
An infant who has been in foster care since birth requires a blood transfusion. Who's authorized to give written, informed consent for the procedure?
1. Foster mother who has been appointed legal guardian
Twenty-four hours after birth, a neonate hasn't passed meconium. This may indicate which condition?
1. Hirschsprung's disease
The nurse is assessing a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display?
1. Holding head erect, 4. Sitting on a firm surface without support, 5. Bearing majority of weight on legs
A baby undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively?
1. Ineffective airway clearance
A 3-month-old admitted to the pediatric unit with meningococcal meningitis has just been assessed by the registered nurse. Which nursing intervention has the highest priority at this time?
1. Instituting droplet precautions
(SELECT ALL THAT APPLY) The nurse is planning to administer an injection of Vitamin K (AquaMEPHYTON) to a neonate. After administering the drug, the nurse should monitor the neonate for which adverse effects?
1. Jaundice 2. Edema. 3. Erythema 4. Pain at the injection site
(SELECT ALL THAT APPLY) The nurse is demonstrating cord care to a mother of a neonate. Which actions should the nurse teach the mother to perform?
1. Keep the diaper below the cord. 4 Only sponge-bathe the neonate until the cord falls off. 5 Clean the length of the cord with alcohol several times daily.
The nurse is teaching child safety to the parents of a 6-month-old who's beginning to crawl. Which point should the nurse include in her teaching?
1. Keeping furniture with sharp corners out of the area where the infant crawls
What are the 3 types of cesarean section cuts that can be made. What are their advantages?
1. Kerr (Transverse) : Allows VBAC for 2nd birth 2. Selheim : Low incision 3. Classical : Fastest(Risk or Trauma), Dihisance Risk, No vaginal supsequent births.
A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to monitor the child's vital signs frequently. Which other action would provide the most important data?
1. Measuring the infant's weight
What are the 2 types of Episiotomies? What are there benefits?
1. Midline (Faster Healing, Less Muscle Damage, Risk of tearing anus) 2. Medial Lateral (Slow healing, More muscle repair, No risk of tearing Anus)
What three test are done to confirm a rupture of the amniotic membranes?
1. Nitrazine Paper (Turn blue to change in pH) 2. Ferning Test (Fluid dried shows fern like design) 3. Free Flow (Cervical exam, pt asked to bear down, fluid seen on cervix)
An infant goes into cardiac arrest. When delivering chest compressions as part of cardiopulmonary resuscitation (CPR), where should the rescuer place her fingers?
1. One fingerbreadth below the nipple line, directly over the sternum
Which intervention should be included in the plan of care for a 6-month-old infant with mild dehydration related to diarrhea and vomiting?
1. Oral electrolyte replacement solutions, breast milk, or lactose-free formula
The parents of a 6-month-old diagnosed with a terminal brain tumor have chosen palliative care for their son. Which intervention will be provided for this infant?
1. Pain management, comfort measures, and support for the parents
A recent abduction of a 2-month-old infant has raised awareness of the need for security plans for hospitals. Which security measure helps ensure the hospitalized infant's security?
1. Placing an identification bracelet on the infant and the parent immediately on admission
A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal?
1. Preventing infection
After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative plan of care should include which nursing action?
1. Removing the restraints every hour
For children from infancy through the preschool years, what is the major stressor posed by hospitalization?
1. Separation from the family
The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of the following is a normal developmental task for an infant this age?
1. Sitting without support
A mother asks the nurse why her 12-month-old baby gets otitis media more frequently than her 10-year-old son. What should the nurse tell her?
1. The baby's eustachian tubes are shorter and lie more horizontally.
A 9-month-old infant is scheduled for an inguinal hernia repair. The divorced parents share joint custody of the infant. What determines who can give informed consent for the procedure?
1. The divorce decree should specify which parent has the right to sign the informed consent form.
(SELECT ALL THAT APPLY) Which of the following instructions should the nurse provide on discharge from the facility to the parents of a neonate who has been circumcised?
1. The neonate must void before being discharged home. 2. Apply petroleum jelly to the glans of the penis with each diaper change. 5 The circumcision requires care for 2 to 4 days after discharge.
A 4-month-old is scheduled for an upper GI series to determine whether the infant has gastroesophageal reflux. The X-ray department is busy and the test, which was scheduled for 8 a.m., becomes delayed until 2 p.m. Which pediatric patient right is being violated by the test delay?
1. To have procedures scheduled so that fluids and food aren't withheld for prolonged periods
The nurse is preparing to administer chloramphenicol (Chloromycetin Otic) to a 2-year-old client with an infection of the external auditory canal. The order reads, "2 drops in the right ear three times per day." Which steps should the nurse take to administer this medication?
1. Wash her hands and arrange supplies at the bedside., 2. Warm the medication to body temperature., 4. Examine the ear canal for drainage.
A 12-month-old child fell down the stairs and a basilar skull fracture is suspected. The nurse should look for:
1. cerebrospinal fluid otorrhea.
A mist tent contains a nebulizer that creates a cool, moist environment for an infant with an upper respiratory tract infection. The cool humidity helps the infant breathe by:
1. decreasing respiratory tract edema.
A healthy, 6-month-old infant is brought to the well-baby clinic for a checkup. When checking the infant's anterior fontanel the nurse expects it to be:
1. open.
If an infant's I.V. access site is in an extremity, the nurse should:
1. use a padded board to secure the extremity.
The physician prescribes furosemide (Lasix), 2 mg/kg P.O., as a one-time dose for an infant with fluid overload. The infant's documented weight is 14 lb. The oral solution contains 10 mg/ml. How many milliliters of solution should the nurse administer?
1.3
A client has just begun taking an oral contraceptive that contains estrogen and progestin. The nurse should explain that full contraceptive benefits won't occur until the client has taken the drug for at least:
10 days.
The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should document this client's blood loss as:
100 ml
Which of the following measurements reflects normal calorie intake for a neonate?
110 to 130 calories per kg
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?
12 months.
The nurse is checking the fetal heart rate (FHR) of a client admitted to the labor and delivery area at term. Which of the following should the nurse identify as the normal range of the baseline FHR?
120 to 160 beats/minute
After receiving methylergonovine (Methergine) I.M. for postpartum hemorrhage, a client is prescribed methylergonovine 0.4 mg by mouth every 6 hours. The pharmacy sends 0.2 mg tablets. How many tablets must the nurse administer with each dose?
2
A primiparous client planning to breast-feed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth breasts begin to fill with milk within which of the following periods?
2 to 4 days
A 9-month-old admitted with pneumonia cries when his parents aren't holding him. He's also unable to sleep. The parents have two other young children at home and can't stay with the infant continually. Which suggestion by the nurse might help the infant sleep?
2. "Can one of you stay and the other one go home and care for your other children?"
A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer?
2. "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs."
The nurse is teaching the mother of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective?
2. "I know that this disease is serious and can lead to asthma."
The nurse is teaching circumcision care to a mother before discharge. Which statement by the mother indicates that teaching was successful?
2. "I should reapply fresh petrolatum gauze after each diaper change."
A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her baby can't sit alone or roll over. An appropriate response by the nurse would be:
2. "Let's see about further developmental testing."
During a well-baby visit, a 2-month-old infant receives diphtheria, tetanus, acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. How should the nurse respond?
2. "This vaccine protects against bacterial infections, such as meningitis and bacterial pneumonia."
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur?
2. 1 week to 1 year, peaking at 2 to 4 months
The nurse expects to observe an infant transferring an object from one hand to another at which age?
2. 6 months
The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?
2. A new cast is needed every 1 to 2 weeks.
The licensed nurse just received the following clients for her shift assignment. Which client should she see first?
2. An 11-month-old infant who's crying and has I.V. fluid infusing
A 2-month-old with a history of hydrocephalus is admitted to the pediatric unit with pneumonia. The infant's respiratory status deteriorates and the physician explains to the family that the infant requires intensive care. The grandmother convinces the parents to refuse transfer and institute comfort measures. Which action should the nurse take?
2. Ask to speak to the parents privately without the grandmother present.
Before a routine checkup in the pediatrician's office, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first?
2. Auscultate the heart and lungs.
The nurse caring for an 8-month-old diagnosed with respiratory syncytial virus is unable to read a medication dosage written in the infant's medical record. What's the only ethical and responsible solution for the nurse?
2. Call the physician and ask for a verbal order to clarify the dosage.
A neonate's pulse rate drops below 60 beats/minute. How should the nurse intervene? Rank in chronological order. Use all the options.
2. Gently shake the neonates shoulders, 3. Call for Help, 1. Place the neonate on a firm, flat surface, 4. Us the hand-tilt-chin-lift method, 5. Assess breathing, and then give 2 slow breaths 6. Give compressions
After surgery to repair a cleft lip, an infant has a Logan bar in place. Which postoperative nursing action is appropriate?
2. Holding the infant semi-upright during feedings
For an 8-month-old infant, which toy promotes cognitive development?
2. Jack-in-the-box
The nurse is teaching the parents of an infant undergoing repair for a cleft lip. Which instructions should the nurse give?
2. Lay the infant on his back or side to sleep., 3. Sit the infant up for each feeding., 5. Clean the suture line after each feeding by dabbing it with saline solution., 6. Give the infant extra care and support.
A neonate was admitted to the pediatric unit with an unexpected congenital defect. What's the best way to involve the parents in the infant's care?
2. Offer the parents opportunities to be involved with the infant's care while they adjust to his unexpected condition.
The nurse is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen?
2. Physical therapist
The nurse is developing a plan to teach a mother how to reduce her baby's risk of developing otitis media. Which of the following directions should the nurse include in the teaching plan?
2. Place the baby in an upright position when giving a bottle.
To obtain the most accurate measurement of an infant's height (length), the nurse should measure which of the following?
2. Recumbent height with the infant supine
A nurse at the family clinic receives a call from the mother of a 5-week-old infant. The mother states that her child was diagnosed with colic at the last checkup. Unfortunately, the symptoms have remained the same. Which teaching instructions are appropriate?
2. Soothe the child by humming and rocking., 4. Burp the infant adequately after feedings., 5. Provide small but frequent feedings to the infant., 6. Offer a pacifier if it isn't time for the infant to eat.
Which of the following is an early sign of heart failure in an infant with a congenital heart defect?
2. Tachycardia
A neonate is recovering from surgery to repair a cleft lip. What should the nurse do to prevent trauma to the suture line?
2. Use a bulb syringe with a rubber tip for feedings.
When collecting data on a postterm neonate, the nurse expects to find:
2. abundant subcutaneous fat.
For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in:
2. an arched, side-lying position, avoiding flexion of the neck onto the chest.
An infant is diagnosed with a congenital hip dislocation. The nurse should expect to note:
2. asymmetrical thigh and gluteal folds.
The nurse is administering I.V. fluids to an infant. Infants receiving I.V. therapy are particularly vulnerable to:
2. fluid overload.
An infant, age 10 months, is brought to the well-baby clinic for a follow-up visit. The mother tells the nurse that she has been having trouble feeding her infant solid foods. To help correct this problem, the nurse should:
2. instruct the mother to place the food at the back and toward the side of the infant's mouth.
A 10-month-old infant with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting:
2. meats.
A mother, who is visibly upset, carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse should:
2. take the infant and mother back to a treatment room.
The nurse is caring for a neonate who has hypospadias. His parents are planning to have the baby circumcised before discharge. When teaching the parents about their child's condition, the nurse should tell them:
2. the foreskin will be needed at the time of surgical correction.
A nulliparous client has been in the latent phase of the first stage of labor for several hours. Despite continued uterine contractions, her cervix hasn't dilated further since the initial examination. Her latent phase may be considered prolonged after:
20 hours.
The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term neonate. Which needle should the nurse use?
25G, 5/8" needle
A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:
3 days of elevated basal body temperature and clear, thin cervical mucus.
A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:
3 full days of elevated basal body temperature and clear, thin cervical mucus.
The parents of an 11-month-old are concerned because the frequency of their infant's bowel movements has decreased from three to four each day to one to two each day. Which response by the nurse is best?
3. "By age 11 months, most infants have one to two bowel movements per day."
A 4-month-old rolls out of the crib and suffers a fractured skull when the nurse who's bathing him turns her back to pick up a towel. As a follow-up to the incident the nurse-manager asks the nurse to document how she could have prevented the injury. Which statement by the nurse is best?
3. "I should have kept one hand on the infant when I turned my back on him."
A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the mother about infant nutritional needs. Which statement by the mother during the current visit indicates effective teaching?
3. "I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated."
For the last 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate (Amoxil) to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician prescribes topical nystatin (Mycostatin) to be applied to the perineum four times daily. Medication teaching should include which instruction?
3. "Inspect your infant's mouth for white patches."
A parent brings her 3-month-old to the clinic for a well-baby examination. Which statement by the parent should concern the nurse?
3. "She's eating rice cereal and applesauce."
The mother of a 12-month-old child expresses concern about the effects of her child's frequent thumb-sucking. After the nurse provides instruction on this topic, which response by the mother indicates that teaching has been effective?
3. "Sucking is important to the baby."
A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate?
3. "We've found that babies can't digest solid food properly until they're 4 months old."
A client who has tested positive for the human immunodeficiency virus (HIV) delivers her baby. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?
3. "Your baby may have acquired HIV in utero, but we won't know for sure until the baby is older."
An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.7 kg). The physician orders ceftriaxone (Rocephin), 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial that yields a dosage strength of 500 mg/2 ml when reconstituted. The nurse should administer how many milliliters?
3. 1.08 ml
Which of the following is the recommended immunization schedule for diphtheria, tetanus, acellular pertussis (DTaP)?
3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years
The nurse expects an infant to sit up without support at which age?
3. 8 months
When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which of the following restraint systems would be safest?
3. A rear-facing infant safety seat in the middle of the backseat
When performing cardiopulmonary resuscitation on a 7-month-old infant, which location would the nurse use to evaluate the presence of a pulse?
3. Brachial artery
The nurse is teaching cardiopulmonary resuscitation (CPR) to the parents of a 1-month-old infant being discharged with an apnea monitor. Which steps are appropriate for performing CPR on an infant?
3. Check for a pulse by palpating the brachial artery., 5. Compress the sternum ½" to 1"., 6. Give five compressions to one breath.
A mother calls the clinic to report that her 9-month-old infant has diarrhea. Upon further questioning, the nurse determines that the child has mild diarrhea and no signs of dehydration. Which advice is most appropriate to give this mother?
3. Continue your baby's normal feedings.
The nurse is caring for a client who has a peripheral I.V. infusing. Which finding by the nurse would lead her to suspect infiltration?
3. Feeling of tightness at the I.V. site
Which finding in an infant suggests congenital hypothyroidism?
3. Hypothermia
During a well-baby visit, a mother asks the nurse about starting her infant on solid foods. The nurse should instruct her to introduce which solid food first?
3. Rice cereal
While preparing to discharge a 9-month-old infant who's recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topic in the teaching session?
3. Safety guidelines
A dehydrated infant is receiving I.V. therapy. The mother tells the nurse she wants to hold her infant but is afraid this might cause the I.V. line to become dislodged. What should the nurse do?
3. Show the mother how to hold the infant properly.
An infant, age 8 months, has a tentative diagnosis of congenital heart disease. During data collection, the nurse measures a heart rate of 170 beats/minute and a respiratory rate of 70 breaths/minute. How should the nurse position the infant?
3. Sitting in an infant seat
(SELECT ALL THAT APPLY) The nurse is performing a neurologic assessment on a 1-day-old neonate. Which of the following findings would indicate possible asphyxia in utero?
3. The neonate's toes don't curl downward when his soles are stroked. 4. The neonate doesn't respond when the nurse claps her hands above him. 6. The neonate displays weak, ineffective sucking.
A 6-month-old is brought to the emergency department with a suspected femur fracture. The parents state that the infant fell from the couch, causing the injury. The X-ray reveals a circular fracture, which is caused by forcibly twisting the extremity. Which action must the nurse take first?
3. Treat the parents professionally and answer their questions appropriately.
When developing a plan of care for a child, the nurse identifies which Eriksonian stage as corresponding to Freud's oral stage of psychosexual development?
3. Trust versus mistrust
While checking a 2-month-old infant's airway, the nurse finds that he isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should:
3. administer five back blows
A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them:
3. as the mother feeds the infant.
Most oral pediatric medications are administered:
3. on an empty stomach.
What concentrations do Pitocin usually come in?
30u/500L 20u/1000L 10u/1000L
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor? 1. Active phase 2. Latent phase 3. Descent phase 4. Transitional phase
4 RATIONALES: In the transitional phase, the cervix dilates from 8 to 10 cm, and intense contractions occur every 1½ to 2 minutes and last for 45 to 90 seconds. In the active phase, the cervix dilates from 5 to 7 cm, and moderate contractions progress to strong contractions that last 60 seconds. In the latent phase, the cervix dilates 3 to 4 cm, and contractions are short, irregular, and mild. No descent phase exists. (Fetal descent may begin several weeks before labor but usually doesn't occur until the second stage of labor.)
Parents of a 6-month-old bring their infant to the pediatrician because he has had diarrhea for the past 3 days. The physician diagnoses gastroenteritis and tells the nurse to instruct the parents on oral rehydration. Which instructions should the nurse give?
4. "Give your baby an electrolyte replacement formula such as Pedialyte for the next 24 hours."
A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching?
4. "Immunizations will have to be delayed until the casts come off."
During a visit to the well-baby clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal?
4. "The baby's stools are bright yellow and soft."
The nurse is teaching parents how to select appropriate toys for their 10-month-old infant. Which statement by the parents indicates effective teaching?
4. "We'll get a push toy for the baby."
The mother of a hospitalized infant appears anxious and displays anger with the staff. Which response by the nurse is most appropriate?
4. "You seem upset. Having you baby hospitalized must be very difficult."
The mother of a hospitalized infant appears anxious and displays anger with the staff. Which response is most appropriate?
4. "You seem upset. Having your child hospitalized must be difficult."
The nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response?
4. "You seem upset. Tell me about it."
A mother is playing with her infant, who's sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be?
4. 10 months
An infant admitted with reactive airway disease is dyspneic and cyanotic. Which intervention takes priority when caring for this infant?
4. Administering albuterol by nebulizer, as prescribed
When planning to administer medication to a 3-month-old infant, the nurse should keep which consideration in mind?
4. An infant's kidneys excrete drugs more slowly than an adult's.
An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?
4. Bulb syringe with tubing
When collecting data on a neonate, the nurse observes a vaguely outlined area of scalp edema. Which term should the nurse use when documenting this observation?
4. Caput succedaneum
A 10-month-old infant is admitted to the facility with dehydration and metabolic acidosis. What is the most likely cause of the infant's dehydration and acidosis?
4. Diarrhea
A 2-month-old baby hasn't received any immunizations. Which immunizations should the nurse prepare to administer?
4. HIB, DTaP, HepB, pneumococcal vaccine (PCV), and IPV
How should a nurse position an infant when administering an oral medication?
4. Held in the bottle- or breast-feeding position
Which sexually transmitted disease is preventable through infant vaccination?
4. Hepatitis B
A child, age 15 months, is recovering from surgery to remove a Wilms' tumor. Which finding best indicates that the child is free from pain?
4. Increased interest in play
Which factor will most likely decrease drug metabolism during infancy?
4. Inefficient liver function
A mother is discontinuing breast-feeding after 3 months. The nurse should advise her to include which item in her infant's diet?
4. Iron-fortified formula alone
An infant arrives at the emergency department in full cardiopulmonary arrest. Efforts at resuscitation fail, and he's pronounced dead. The cause of death is sudden infant death syndrome (SIDS). Which of the following is true regarding the etiology of SIDS?
4. It occurs more commonly in infants who sleep in the prone position.
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child?
4. Maintaining a consistent, structured environment
A licensed practical nurse is helping a registered nurse admit an infant with acute gastroenteritis. Which intervention takes priority?
4. Obtaining a history of the illness
The nurse is caring for a 10-month-old client with Down syndrome. Which intervention by the nurse is most appropriate?
4. Offer assistance and support to the parents.
In planning the care of an infant undergoing phototherapy for hyperbilirubinemia, which of the following would be least appropriate?
4. Performing frequent visual assessments of jaundice
What is the recommended treatment for scabies in a child who's younger than age 1?
4. Permethrin (Elimite)
A 6-week-old infant is brought to the clinic for a well-baby visit. To check the fontanels, how should the nurse position the infant?
4. Seated upright
Which data collection finding would the nurse identify as abnormal for a 4-month-old infant?
4. The spaces between the ribs (intercostal) are delineated during inspiration.
Which data collection finding would lead the nurse to suspect dehydration in a preterm neonate?
4. Urine output below 1 ml/hour
Which safeguard should the nurse employ with I.V. fluid administration for an infant?
4. Using an infusion pump to regulate the flow rate
When administering an oral medication to an infant, the nurse should take which action to minimize the risk of aspiration?
4. Using an oral syringe to place the medication beside the tongue
When administering an I.M. injection to an infant, the nurse should use which site?
4. Vastus lateralis
The nurse must administer a liquid medication to an infant. Which step should the nurse take first?
4. Verify the physician's order.
Which intervention provides the most accurate information about an infant's hydration status?
4. Weighing the infant daily
A 4-month-old infant is taken to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the baby has failed to gain expected weight and recommends that the baby have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that:
4. a low-intensity, painless electrical current is applied to the skin.
A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds he still isn't breathing and has no pulse. The nurse should then:
4. call for assistance.
The nurse is preparing for the discharge of a neonate with a cleft lip and palate. One of the nurse's major concerns is to:
4. establish an adequate feeding pattern.
In a 3-month-old infant, fluid and electrolyte imbalance can occur quickly, primarily because an infant has:
4. immature kidney function.
A client plans to bottle-feed her full-term neonate. What is the normal feeding pattern for a full-term neonate during the 24 hours after delivery?
40 to 60 ml of formula every 2 to 4 hours
A client in labor is prescribed 1,000 ml of normal saline solution to infuse over 6 hours. The drip factor of the I.V. administration set is 15 drops/ml. The nurse on the previous shift hung the solution at the end of her shift. The oncoming nurse should recheck the drip rate to make sure that the I.V. is infusing at the prescribed drip rate. What is the prescribed drip rate?
42 drops/minute
Which percentage of postpartum clients experiences "postpartum blues?"
50-80%
A nurse is providing teaching to a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day?
500
A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?
6 months.
During neonatal resuscitation immediately after delivery, chest compressions should be initiated when the heart rate falls below how many beats per minute?
60
The uterus returns to the pelvic cavity in which of the following time frames?
7 to 9 days postpartum
The nurse must administer a medication to an infant based on his weight in kilograms. The clients weight in pounds is 16. What is the client's weight in kilograms?
7.3
According to Ballard assessment scale, what size determines and large for gestational age baby and a small for gestational age baby? What measurements are used to get to this score?
>90% growth = LGA <10% growth = SGA 1. Head Circumference 2. Crown to Rump Distance 3. Femur Length
A nurse is preparing to perform phenylketonuria (PKU) testing. Which baby is ready for the nurse to test?
A 2-day-old baby who has been breast-fed
Which client care assignment is the most appropriate assignment for a newly graduated licensed practical nurse (LPN)?
A 24-year-old primigravida who delivered a 6-lb, 4-oz (2,835-g) baby vaginally 4 hours ago and is unable to void
The nurse is assigned to care for four neonates. Which neonate should she assess first?
A 4-hour-old, 10-lb, 7-oz (4,734 g) boy delivered vaginally
Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body requirements related to poor sucking?
A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day
Which of the following describes a preterm neonate?
A neonate born at less than 37 weeks' gestation regardless of weight
Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes?
A neonate who's in good condition
A primiparous client, who has just given birth to a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following?
A normal response to the birth
The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which of the following clients should the nurse assess first?
A primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally
An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large infants, to shorten the second stage of labor, or for a malpresentation. The nurse caring for the mother following an assisted birth should keep which of the following in mind?
A vacuum extractor is safer than forceps because it causes less trauma to the baby and the mother's perineum.
A client is recovering in the labor and delivery area after delivering a 6-lb, 3-oz boy. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings?
A vaginal laceration
When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following descriptions provides an accurate picture of retention with overflow?
A varying urge to urinate with an average output of 100 ml
The nurse is providing preoperative teaching to the parents of a 9-month-old infant who is having surgery to repair a ventricular septal defect. Identify the area of the heart where the defect is located.
A ventricular septal defect is a hole in the septum between the ventricles. The defect can be anywhere along the septum but is most commonly located in the middle of the septum.
2. The neonate's respiratory function usually stabilizes at 24 hours after birth and is maintained by biochemical and environmental stimulation. What four physiologic conditions must be present in order for the neonate's respiratory function to proceed normally? A. Functioning respiratory center, patent airway, intact nerves from the brain to the chest muscles and adequate caloric intake B. Functioning respiratory center, patent airway, closure of fetal shunts and intact nerves from the brain to the chest muscles C. Normothermia, patent airway, functioning respiratory center and adequate calories D. Closure of fetal shunts, functioning respiratory center, patent airway and intact nerves from the brain to the chest muscles
A. Functioning respiratory center, patent airway, intact nerves from the brain to the chest muscles and adequate caloric intake Rationale: Respiratory function requires a functioning respiratory center, intact nerves from the brain to the chest muscles and adequate caloric intake to supply energy for the work of respiration. With birth comes functional closure of fetal shunts but actual closure may not be accomplished until 4 weeks after birth. Clinically insignificant functional murmurs and transient cyanosis may result. Maintaining the newborn's body temperature is essential for successful transition to extrauterine life but not for maintaining respiratory function.
After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What does this finding suggest?
Abruptio placentae
The nurse is evaluating the client who gave birth vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breastfeeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client?
Acetaminophen and hydrocodone 10 mg 1 tab P.O. q 4 to 6 hr p.r.n.
At her follow-up examination, a client who's 6 weeks postpartum tells the nurse that she's exhausted and sore from breast-feeding and wants to formula-feed her baby. She also mentions that she feels like a failure and finds it increasingly difficult "just to get out of bed in the morning." Which intervention should the nurse attempt before notifying the physician?
Acknowledging the client's feelings, asking about other life stressors, and identifying the client's support system
A postpartum client tells the nurse she isn't having regular bowel movements. The nurse should recommend that the client do what to combat constipation?
Add high-fiber foods to her diet.
A primipara who is Rho(D)-negative has just given birth to an Rh-positive baby. Which priority nursing intervention should be included in the plan of care?
Administer Rho(D) immune globulin to the client within 3 days
After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline and her breasts are soft. She has scant lochia and a negative Homans' sign. The client reports pain in her lower back. Which of the following should the nurse do next?
Administer an ordered mild analgesic.
Which action should the nurse perform if the client's blood pressure falls during the first or second stage of labor?
Administer oxygen through a face mask at 6 to 10 L/minute.
A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?
Administer pain medication per order.
The nurse is assisting in developing a care plan for a client who had an episiotomy. Which interventions would be included for the nursing diagnosis acute pain related to perineal sutures?
Administer sitz baths three to four times per day and encourage the client to do Kegel exercises.
One day after having a cesarean birth, a client complains of incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug?
Administer the drug with meals or milk.
The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rho(D)-negative and her baby is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?
Administration of Rho(D) immune globulin I.M. to the mother within 72 hours
A breast-feeding client is diagnosed with mastitis. Which nursing intervention would be most helpful to her?
Advising her to massage the affected area gently while breast-feeding
Which of the following physiologic changes during labor makes it necessary for the nurse to check blood pressure frequently?
Alterations in cardiovascular function affect the fetus.
Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
An increased sense of rectal pressure
A 6-month-old infant is found floating face down in a swimming pool. A neighbor, who is a nurse, assesses for the presence of respirations and a pulse. Identify the area that is most appropriate to check for a pulse.
An infant's pulse is most accessible at the brachial artery. The brachial artery is located inside the upper arm between the elbow and the shoulder. Cardiopulmonary resuscitation guidelines recommend using this area to assess for a pulse.
Late in the first stage of labor, a client receives a spinal block to relieve discomfort. A short time later, her husband tells the nurse that his wife feels dizzy and is complaining of numbness around her lips. What do the client's symptoms suggest?
Anesthesia overdose
A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which of the following would be the nurse's initial action? 1. Assess for presence of a full bladder. 2. Suggest the placement of an internal uterine pressure catheter to determine adequacy of contractions. 3. Encourage the mother to relax by assisting her with appropriate breathing techniques. 4. Suggest to the physician that oxytocin augmentation be started to stimulate labor.
Answer: 1 RATIONALES: A full bladder will slow or stop cervical dilation and produce symptoms that could be misdiagnosed as arrest in labor. Other strategies, such as internal uterine monitoring, relaxation, and oxytocin augmentation, would be appropriate later, but assessing the bladder first is key.
The nurse observes a late deceleration. It's characterized by and indicates which of the following? 1. U-shaped deceleration occurring after the first half of the contraction, indicating uteroplacental insufficiency 2. U-shaped deceleration occurring with the contraction, indicating cord compression 3. V-shaped deceleration occurring after the contraction, indicating uteroplacental insufficiency 4. Deep U-shaped deceleration occurring before the contraction, indicating head compression
Answer: 1 RATIONALES: A late deceleration is U-shaped and occurs after the first half of the contraction, indicating uteroplacental insufficiency. It's an ominous pattern and requires immediate action — such as administering oxygen, repositioning the mother, and increasing the I.V. infusion rate — to correct the problem. U- and V-shaped decelerations are variable decelerations occurring at unpredictable times during contractions and are related to umbilical cord compression. Deep U-shaped deceleration occurring before the contraction is early deceleration.
For a client who's moving into the active phase of labor, the nurse should include which of the following as the priority of care? 1. Offer support by reviewing the short-pant form of breathing. 2. Administer narcotic analgesia. 3. Allow the mother to walk around the unit. 4. Watch for rupture of the membranes.
Answer: 1 RATIONALES: By helping the client use the pant form of breathing, the nurse can help the client manage her contractions and reduce the need for opioids and other forms of pain relief, which can have an effect on fetal outcome. In the active phase, the mother most likely is too uncomfortable to walk around the unit. The nurse will observe for rupture of membranes and may administer opioid analgesia but these don't take priority.
A primigravid client is admitted to the labor and delivery area. Assessment reveals that she's in the early part of the first stage of labor. Her pain is likely to be most intense: 1. around the pelvic girdle. 2. around the pelvic girdle and in the upper legs. 3. around the pelvic girdle and at the perineum. 4. at the perineum.
Answer: 1 RATIONALES: During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, pain spreads to the upper legs and perineum. During the late part of the second stage and during childbirth, intense pain occurs at the perineum.
Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation? 1. Breech position 2. Late decelerations 3. Entrance into the second stage of labor 4. Multiple gestation
Answer: 1 RATIONALES: Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.
Which of the following describes the term fetal position? 1. Relationship of the fetus's presenting part to the mother's pelvis 2. Fetal posture 3. Fetal head or breech at cervical os 4. Relationship of the fetal long axis to the mother's long axis
Answer: 1 RATIONALES: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis.
During labor, a client asks the nurse why her blood pressure must be measured so often. Which explanation should the nurse provide? 1. Blood pressure reflects changes in cardiovascular function, which may affect the fetus. 2. Increased blood pressure indicates that the client is experiencing pain. 3. Increased blood pressure signals the peak of the contraction. 4. Medications given during labor affect blood pressure.
Answer: 1 RATIONALES: Frequent blood pressure measurement helps determine whether maternal cardiovascular function is adequate. During contractions, blood flow to the intervillous spaces changes, compromising fetal blood supply. Increased blood pressure is expected during pain and contractions. Measuring blood pressure frequently helps determine whether blood pressure has returned to precontraction levels, ensuring adequate blood flow to the fetus. Although medications given during labor can affect blood pressure, the main purpose of measuring blood pressure is to verify adequate fetal status.
When assessing a client who has just delivered a neonate, the nurse finds that the fundus is boggy and deviated to the right. What should the nurse do? 1. Have the client void. 2. Assess the client's vital signs. 3. Evaluate lochia characteristics. 4. Massage the fundus.
Answer: 1 RATIONALES: Having the client void can determine whether the boggy, deviated fundus results from a full bladder — the most common cause of these fundal findings. Vital sign assessment is unnecessary unless the nurse suspects hemorrhage from delayed involution. In a client who doesn't have a full bladder, the nurse should evaluate lochia characteristics to detect possible hemorrhage. If the client has a full bladder, massaging the fundus won't stimulate uterine contractions (which aid uterine involution) or prevent uterine atony — a possible cause of hemorrhage.
The nurse applies an external electronic fetal monitor (EFM) to assess a client's uterine contractions and evaluate the fetal heart rate (FHR). However, the client is uncomfortable and changes positions frequently, making FHR hard to assess. Consequently, the physician decides to switch to an internal EFM. Before internal monitoring can begin, which of the following must occur? 1. The membranes must rupture. 2. The client must receive anesthesia. 3. The cervix must be fully dilated. 4. The fetus must be at 0 station.
Answer: 1 RATIONALES: Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm and when the presenting part is at least at -1 station. Anesthesia isn't required for internal EFM.
A client, age 19, goes into labor at 40 weeks' gestation. When assessing the fetal monitor strip, the nurse sees that the fetal heart rate (FHR) has decreased to 60 beats/minute and that the waveforms sometimes resemble a V and begin and end abruptly. The nurse should interpret this pattern as: 1. variable decelerations. 2. decreased short-term variability. 3. increased long-term variability. 4. early decelerations.
Answer: 1 RATIONALES: On a fetal monitor strip, variable decelerations are characterized by an FHR that commonly decreases to 60 beats/minute; waveform shapes that vary and may resemble the letter U, V, or W; and deceleration waveforms with an abrupt onset and recovery. Decreased short-term variability manifests as fewer than 2 to 3 beats/amplitude of the baseline FHR. Increased long-term variability manifests as more than 5 to 20 beats/minute of the baseline FHR in rhythmic fluctuation. Early decelerations are seen as the descent, peak, and recovery of the deceleration waveform that mirrors the contraction waveform.
During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin (Pitocin). When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? 1. Contractions will be stronger and more uncomfortable and will peak more abruptly. 2. Contractions will be weaker, longer, and more effective. 3. Contractions will be stronger, shorter, and less uncomfortable. 4. Contractions will be stronger and shorter and will peak more slowly.
Answer: 1 RATIONALES: Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions. Oxytocin doesn't affect the duration of contractions.
The nurse is administering oxytocin (Pitocin) to a client in labor. During oxytocin therapy, why must the nurse monitor the client's fluid intake and output closely? 1. Because oxytocin causes fluid retention 2. Because oxytocin causes excessive thirst 3. Because oxytocin has a diuretic effect
Answer: 1 RATIONALES: Oxytocin has an antidiuretic effect; prolonged I.V. infusion may lead to severe fluid retention, resulting in seizures, coma, and even death. Excessive thirst results from the work of labor and lack of oral fluids, not oxytocin administration. Oxytocin isn't toxic to the kidney.
At 28 weeks' gestation, a client is admitted to the labor and delivery area in preterm labor. An I.V. infusion of ritodrine (Yutopar) is started. Which client outcome reflects the nurse's awareness of an adverse effect of ritodrine? 1. "The client remains free from tachycardia." 2. "The client remains free from polyuria." 3. "The client remains free from hypertension." 4. "The client remains free from hyporeflexia."
Answer: 1 RATIONALES: Ritodrine and other beta-adrenergic agonists may cause tachycardia, hypotension, bronchial dilation, increased plasma volume, increased cardiac output, arrhythmias, myocardial ischemia, reduced urine output, restlessness, headache, nausea, and vomiting. These drugs aren't associated with polyuria, hypertension, or hyporeflexia.
A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer: 1. ritodrine (Yutopar). 2. bromocriptine (Parlodel). 3. magnesium sulfate. 4. betamethasone (Celestone).
Answer: 1 RATIONALES: Ritodrine reduces frequency and intensity of uterine contractions by stimulating B2 receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia — a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother).
A diabetic client in labor tells the nurse she has had trouble controlling her blood glucose level recently. She says she didn't take her insulin when the contractions began because she felt nauseated; about an hour later, when she felt better, she ate some soup and crackers but didn't take insulin. Now, she reports increased nausea and a flushed feeling. The nurse notes a fruity odor to her breath. What do these findings suggest? 1. Diabetic ketoacidosis 2. Hypoglycemia 3. Infection 4. Transition to the active phase of labor
Answer: 1 RATIONALES: Signs and symptoms of diabetic ketoacidosis include nausea and vomiting, a fruity or acetone breath odor, signs of dehydration (such as flushed, dry skin), hyperglycemia, ketonuria, hypotension, deep and rapid respirations, and a decreased level of consciousness. In contrast, hypoglycemia causes sweating, tremors, palpitations, and behavioral changes. Infection causes a fever. Transition to the active phase of labor is signaled by cervical dilation of up to 7 cm and contractions every 2 to 5 minutes.
Because cervical effacement and dilation aren't progressing in a client in labor, the physician orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the client's fluid intake and output closely during oxytocin administration? 1. Oxytocin causes water intoxication. 2. Oxytocin causes excessive thirst. 3. Oxytocin is toxic to the kidneys. 4. Oxytocin has a diuretic effect.
Answer: 1 RATIONALES: The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake — not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.
When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following? 1. Fetal hypoxia 2. The contraction pattern 3. The status of a trapped cord 4. Maternal comfort
Answer: 1 RATIONALES: These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort.
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? 1. Change the client's position. 2. Prepare for emergency cesarean section. 3. Check for placenta previa. 4. Administer oxygen.
Answer: 1 RATIONALES: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression.
The nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? 1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry 2. Acidic pH of fluid when tested with nitrazine paper 3. Presence of amniotic fluid in the vagina 4. Cervical dilation of 6 cm 5. Alkaline pH of fluid when tested with nitrazine paper
Answer: 1,3,5 RATIONALES: The fernlike pattern that occurs when vaginal fluid is placed on a glass slide and allowed to dry, presence of amniotic fluid in the vagina, and alkaline pH of fluid are all signs of ruptured membranes. The fernlike pattern seen when the fluid is allowed to dry on a slide is a result of the high sodium and protein content of the amniotic fluid. The presence of amniotic fluid in the vagina results from the expulsion of the fluid from the amniotic sac. Cervical dilation and regular contractions are signs of progressing labor but don't indicate PROM.
The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be prepared for which maternal adverse reactions? 1. Hypertension 2. Jaundice 3. Dehydration 4. Fluid overload 5. Uterine tetany 6. Bradycardia
Answer: 1,4,5 RATIONALES: Adverse reactions to oxytocin in the mother include hypertension, fluid overload, and uterine tetany. The antidiuretic effect of oxytocin increases renal reabsorption of water, leading to fluid overload — not dehydration. Jaundice and bradycardia are adverse reactions that may occur in the neonate. Tachycardia, not bradycardia, is reported as a maternal adverse reaction.
The nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should include which nursing diagnosis in the client's care plan? 1. Anxiety related to the facility environment 2. Fear related to a potentially difficult childbirth 3. Compromised family coping related to hospitalization 4. Acute pain related to labor contractions
Answer: 2 RATIONALES: A client's ability to cope during labor and delivery may be hampered by fear of a painful or difficult childbirth, fear of loss of control or self-esteem during childbirth, or fear of fetal death. A previous negative experience may increase these fears. Therefore, Fear related to a potentially difficult childbirth is the most appropriate nursing diagnosis. The client's anxiety stems from her past history of a long labor, not from being in the facility; therefore a diagnosis of Anxiety related to the facility environment isn't warranted. There is no evidence of compromised family coping related to hospitalization. Although acute pain related to labor contractions may be a problem, this isn't mentioned in the question.
When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be which of the following? 1. Shorter than her first labor 2. About half as long as her first labor 3. About the same length of time as her first labor 4. A length of time that can't be determined based on her first labor
Answer: 2 RATIONALES: A woman having her second baby can anticipate a labor about half as long as her first labor. The other options are incorrect.
The physician decides to artificially rupture the membranes. Following this procedure, the nurse checks the fetal heart tones for which reason? 1. To determine fetal well-being 2. To assess for fetal bradycardia 3. To assess fetal position 4. To prepare for an imminent delivery
Answer: 2 RATIONALES: After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.
During the active phase of the first stage of labor, a client undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority? 1. Deficient knowledge (testing procedure) related to amniotomy 2. Ineffective fetal cerebral tissue perfusion related to cord compression 3. Acute pain related to increasing strength of contractions 4. Risk for infection related to rupture of membranes
Answer: 2 RATIONALES: Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed by the presenting fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen supply. Because lack of oxygen to the fetus may cause fetal death, the nursing diagnosis of Ineffective fetal cerebral tissue perfusion takes priority over diagnoses of Deficient knowledge, Acute pain, and Risk for infection.
A client with Rh isoimmunization delivers a neonate with an enlarged heart and severe, generalized edema. Which nursing diagnosis is most appropriate for this client? 1. Ineffective denial related to a socially unacceptable infection 2. Impaired parenting related to the neonate's transfer to the intensive care unit 3. Deficient fluid volume related to severe edema 4. Fear related to removal and loss of the neonate by statute
Answer: 2 RATIONALES: Because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of Impaired parenting related to the neonate's transfer to the neonatal intensive care unit. (Another pertinent nursing diagnosis may be Compromised family coping related to lack of opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.
After admission to the labor and delivery area, a client undergoes routine tests, including a complete blood count, urinalysis, Venereal Disease Research Laboratory test, and gonorrhea culture. The gonorrhea culture is positive, although the client lacks signs and symptoms of this disease. What is the significance of this finding? 1. Maternal gonorrhea may cause a neural tube defect in the fetus. 2. Maternal gonorrhea may cause an eye infection in the neonate. 3. Maternal gonorrhea may cause acute liver changes in the fetus. 4. Maternal gonorrhea may cause anemia in the neonate.
Answer: 2 RATIONALES: Gonorrhea in the cervix may cause neonatal eye infection during delivery as well as a serious puerperal infection in the client. Maternal gonorrhea isn't associated with neural tube defects, acute fetal liver changes, or neonatal anemia.
A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for: 1. uterine inversion. 2. uterine atony. 3. uterine involution. 4. uterine discomfort.
Answer: 2 RATIONALES: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.
At 40 weeks' gestation, a client is admitted to the labor and delivery area. She and her husband are worried about the fetus's health because she had problems during her previous childbirth. The nurse reassures them that the fetus will be monitored closely with an electronic fetal monitor (EFM). On the fetal monitor strip, what is the single most reliable indicator of fetal well-being? 1. Normal long-term variability 2. Normal short-term variability 3. Normal baseline fetal heart rate (FHR) 4. Normal contraction sequence
Answer: 2 RATIONALES: Normal short-term variability — 2 to 3 beats per amplitude — is the single most reliable indicator of fetal well-being on an EFM strip. It represents actual beat-to-beat fluctuations in the FHR. Normal long-term variability, although a helpful indicator, takes into account larger periodic and rhythmic deviations above and below the baseline FHR. Baseline FHR serves only as a reference for all subsequent FHR readings taken during labor. Contraction sequence provides no information about fetal well-being, although it does give some indication of maternal well-being and progress.
Several minutes after a vaginal delivery, nursing assessment reveals blood gushing from the client's vagina, umbilical cord lengthening, and a globular-shaped uterus. The nurse should suspect which condition? 1. Cervical or vaginal laceration 2. Placental separation 3. Postpartum hemorrhage 4. Uterine involution
Answer: 2 RATIONALES: Placental separation is characterized by a sudden gush or trickle of blood from the vagina, further protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. With cervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartum hemorrhage, usually caused by uterine atony, the uterus isn't globular. Uterine involution can't begin until the placenta has been delivered.
The nurse notices that a large number of clients who receive oxytocin (Pitocin) to induce labor, vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene? 1. Notify the physicians and explain that they need to teach their clients before inducing labor. 2. Initiate a unit policy involving staff nurses, certified nurse midwives, and physicians in teaching clients before labor induction. 3. Report the physicians for providing inferior care. 4. Initiate a protocol order that allows the nurse to administer promethazine (Phenergan) before administering oxytocin.
Answer: 2 RATIONALES: The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Option 1 blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the problem — the lack of client education.
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? 1. Active phase 2. Latent phase 3. Expulsive phase 4. Transitional phase
Answer: 2 RATIONALES: The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.
A client is admitted to the labor and delivery area. How can the nurse most effectively determine the duration of the client's contractions? 1. By timing the period between one contraction and the beginning of the next contraction 2. By timing the period from the onset of uterine tightening to uterine relaxation 3. By timing the period from the increment (building-up) phase to the acme (peak) phase 4. By timing the period from the acme (peak) phase to the decrement (letting-down) phase
Answer: 2 RATIONALES: To determine the duration of contractions, the nurse should time the period from the onset of uterine tightening to uterine relaxation. Timing the period between one contraction and the beginning of the next contraction helps determine the frequency of contractions. Timing the period from the increment to the acme or from the acme to the decrement supplies only partial information about contractions.
An adolescent in the early stages of labor is admitted to the labor and delivery unit. The nurse notes lymphadenopathy and a macular rash on the palmar surfaces of the hands and plantar surfaces of the feet. Admission laboratory testing reveals trace ketones in the urine, white blood cell count 10,000/μl, hemoglobin 14.5 g/dl, hematocrit 40%, and the nontreponemal antibody test is positive. The nurse notifies the physician of the laboratory results. Which action by the nurse takes priority? 1. Notifying the laboratory that a repeat hemoglobin and hematocrit have been ordered. 2. Recommending that the client drink plenty of fluids. 3. Consulting with the infection control nurse. 4. Asking the client if she has been exposed to varicella in the past 3 weeks.
Answer: 3 RATIONALES: A nontreponemal test screens the client for syphilis. The positive test result, along with the lymphadenopathy and rash, indicate that the client has secondary syphilis. Based on these findings, the neonate will most likely have signs and symptoms of congenital syphilis. The hemoglobin and hematocrit results are normal for a pregnant client. The laboratory results don't show signs of dehydration, so having the client drink plenty of fluids isn't necessary. The lesions associated with varicella are vesicular, and don't resemble the rash associated with syphilis.
A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her care plan? 1. Carefully titrating the oxytocin based on her pattern of labor 2. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes 3. Allowing the client to ambulate as tolerated 4. Helping the client use breathing exercises to manage her contractions
Answer: 3 RATIONALES: Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include.
The nurse is assessing the fetal heart rate (FHR) of a client, who is at term, admitted to the labor and delivery area. Which of the following should the nurse identify as the normal range of the baseline FHR? 1. 60 to 80 beats/minute 2. 80 to 120 beats/minute 3. 120 to 160 beats/minute 4. 160 to 200 beats/minute
Answer: 3 RATIONALES: In a full-term fetus, the baseline FHR normally ranges from 120 to 160 beats/minute. FHR below 120 beats/minute reflects bradycardia; above 160 beats/minute, tachycardia.
Which of the following would be an inappropriate indication of placental detachment? 1. An abrupt lengthening of the cord 2. An increase in the number of contractions 3. Relaxation of the uterus 4. Increased vaginal bleeding
Answer: 3 RATIONALES: Relaxation isn't an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus.
The third stage of labor ends with which of the following? 1. The birth of the baby 2. When the client is fully dilated 3. After the delivery of the placenta 4. When the client is transferred to her postpartum bed
Answer: 3 RATIONALES: The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the baby. The fourth stage of labor includes the first 4 hours after birth.
During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a precipitous delivery by: 1. applying counterpressure to the fetus's head. 2. encouraging the client to push. 3. massaging and supporting the perineum. 4. instructing the client to contract the perineal muscles.
Answer: 3 RATIONALES: The nurse can help control a precipitous delivery by stretching the labia, such as by massaging and bracing the perineum with gentle back pressure. This helps prevent perineal lacerations — the primary maternal complication of precipitous delivery. Applying counterpressure to the fetus's head reduces perineal stress temporarily; however, delivery proceeds when the client pushes with uterine contractions. Pushing puts further stress on the perineum, promoting delivery. When the fetus's head exerts pressure on the perineum, contracting the perineal muscles is virtually impossible.
A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next? 1. Tell the client that smoking is prohibited in the facility, and that if she smokes again, she'll be discharged. 2. Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close by. 3. Notify the physician and security immediately. 4. Ask the nursing assistant to dispose of the marijuana that the client can't smoke anymore.
Answer: 3 RATIONALES: The nurse should immediately notify the physician and security. The physician must be informed because illegal drugs can interfere with the labor process and affect the neonate after delivery. Moreover, the client might have consumed other illegal drugs. The nurse should also inform security who are specially trained to handle such situations. Most hospitals prohibit smoking. The nurse needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is prohibited. Smoking is dangerous around oxygen and it's fine for the nurse to explain the hazard to the client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be asked to dispose of the marijuana.
A client in the fourth stage of labor asks to use the bathroom for the first time since delivery. The client has oxytocin (Pitocin) infusing. Which response by the nurse is best? 1. "You'll have to wait until the vaginal bleeding stops." 2. "You'll have to wait until the oxytocin is infused." 3. "You may use the bathroom with my assistance." 4. "You may get up to the bathroom whenever you need to."
Answer: 3 RATIONALES: The nurse should tell the client that she may use the bathroom with the nurse's assistance. The nurse should assist the client for the client's first trip to the bathroom after delivery. It isn't uncommon for a client to faint after delivery. Telling the client she must wait until her vaginal bleeding stops is inappropriate; vaginal bleeding continues for about 6 weeks after delivery. The nurse shouldn't tell the client she can get up whenever she needs to use the bathroom; doing so places the client at risk for injury.
When caring for a client with preeclampsia, which action is a priority? 1. Monitoring the client's labor carefully and preparing for a fast delivery 2. Continually assessing the fetal tracing for signs of fetal distress 3. Checking vital signs every 15 minutes to watch for increasing blood pressure 4. Reducing visual and auditory stimulation
Answer: 4 RATIONALES: A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're of a lesser priority.
A nulliparous client has been in the latent phase of the first stage of labor for several hours. Despite continued uterine contractions, her cervix hasn't dilated further since the initial examination. Her latent phase may be considered prolonged after: 1. 6 hours. 2. 10 hours. 3. 14 hours. 4. 20 hours.
Answer: 4 RATIONALES: Based on research, the latent phase may be considered prolonged if it exceeds 20 hours in a nulliparous client or 14 hours in a multiparous client.
The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
Answer: 4 RATIONALES: Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can contribute to hypotension because of uterine pressure on the great vessels.
During assessment for admission to the labor and delivery area, a client and her husband ask the nurse whether their sons, ages 8 and 10, can witness the childbirth. Before answering this question, the nurse should consider which guideline? 1. The children and client should share a support person during the childbirth. 2. Children should attend childbirth only if it takes place at home. 3. Children shouldn't attend childbirth because it will frighten them. 4. Each child attending the childbirth should have a separate support person.
Answer: 4 RATIONALES: Each child attending the childbirth should have a support person — one who isn't also serving as the client's support person. The support person explains what is happening, reassures the child, and removes the child from the area if an emergency occurs or if the child becomes frightened. Children can attend childbirth in any setting. The decision to have a child present hinges on the child's developmental level, ability to understand the experience, and amount of preparation.
A client with active genital herpes is admitted to the labor and delivery area during the first stage of labor. Which type of birth should the nurse anticipate for this client? 1. Mid forceps 2. Low forceps 3. Induction 4. Cesarean
Answer: 4 RATIONALES: For a client with active genital herpes, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Mid forceps and low forceps are types of vaginal births that could transmit the herpes infection to the neonate. Induction is used only during vaginal birth; therefore, it's inappropriate for this client.
For a client who's fully dilated, which of the following actions would be inappropriate during the second stage of labor? 1. Positioning the mother for effective pushing 2. Preparing for delivery of the baby 3. Assessing vital signs every 15 minutes 4. Assessing for rupture of membranes
Answer: 4 RATIONALES: In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor. Positioning for effective pushing, preparing for delivery, and assessing vital signs every 15 minutes are appropriate actions at this time.
A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. Who should the nurse manager consult to help the staff cope with this unexpected death? 1. The human resource director, so she can arrange vacation time for the staff 2. The physician, so he can provide education about HELLP syndrome 3. The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff 4. The chaplain, because his educational background includes strategies for handling grief
Answer: 4 RATIONALES: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.
The nurse is caring for a client who's in the first stage of labor. What is the shortest but most difficult part of this stage? 1. Active phase 2. Complete phase 3. Latent phase 4. Transitional phase
Answer: 4 RATIONALES: The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4½ to 6 hours; it's characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.
A nurse is assessing a premature infant. What would initially alert the nurse that the infant is having respiratory distress? A. Flaring nostrils B. Sporadic crying C. Ineffective cough D. Decreased pulse rate
Answer: A Rationale: In attempt to increase intake of oxygen, the respiratory rate increases with flaring of nostrils as a cardinal sign. It is significant to note that when a neonate is in respiratory distress, the rate of respirations will increase. Sporadic crying, ineffective cough, and decreased pulse rate may be indicative of infant distress but are not classic signs of respiratory distress.
When performing a physical assessment of an unusually small newborn infant, the nurse can determine that the infant is small for gestation age (SGA) rather than premature by which of the following characteristics? A. vigorous cry B. increased lanugo C. weaking sucking reflex D. diminished ear recoil
Answer: A Rationale: In contrast to a premature infant, an SGA baby has a vigorous cry and appears alert. Increased lanugo, weak sucking reflex, and diminished ear recoil are all present in the premature newborn that is physiologically underdeveloped.
Which statement is accurate regarding the reason premature infants develop neonatal respiratory distress syndrome? A. the alveoli lack surfactant B. the lungs lack ability to absorb oxygen C. the lungs cannot remove CO2 from the blood D. immature lungs cannots exchange CO2 and O2 effecively.
Answer: A Rationale: Surfactant is a sticky lubricant on the surface of the alveoli that essentially maintains patency of the alveoli in newborns. Premature infants lack surfactant, which causes the alveoli to collapse and requires increasing effort to reexpand the alveoli. Immature lungs are able to exchange O2 and CO2 but without surfactant, the alveoli collapse and cannot reexpland without ventilatory assistance.
Which disorder seen in newborns consists of right ventricular hypertrophy, stenosis of the pulmonary artery, ventricular septal defect, and overriding of the aorta? A. Tetralogy of Fallot B. Atrial septal defect C. Coarctation of the aorta D. Ventricular septal defect
Answer: A Rationale: Tetralogy of Fallot is a major heart defect resulting in cyanosis at birth. The classic cyanotic symptoms result from these four congenital defects: right ventricular hypertrophy, stenosis of the pulmonary artery, ventricular septal defect, and overriding of the aorta. Atrial septal defect is an abnormal opening between the right and the left atria with a left-to-right shunting of blood. Coarctation of the aorta is a localized narrowing of the aorta causing increased pressure proximal to the defect (head and neck). There is decreased pressure distal to the defect, which is the body and lower extremities. Ventricular septal defect is an abnormal opening between the right and left ventricles. High pressure in the left ventricle causes blood to shunt from the left to the right ventricle.
A new mother expresses concern over strabismus in her infant. What would the nurse explain to the mother regarding this condition? A. it is a normal finding in newborns B. this may be a permanent defect C. it will require corrective surgery D. it will result in impaired vision
Answer: A Rationale: Muscle control of the eyes in the newborn is undeveloped, resulting in temporary strabismus (pseudostrbismus), or a cross-eyed appearance. This is considered normal in the newborn and usually corrects by the 3rd to 4th month. Strabismus is not a permanent defect, does not require corrective surgery, and does not cause impaired vision.
A newborn infant is diagnosed with a patent ductus arteriosus (PDA). The nurse is aware that this is indicative of a defect that: A. typically results in cyanosis B. may result in congestive heart failure C. also causes pulmonary stenosis D. normally does not close after birth
Answer: B Rationale: Defects that result in increased pulmonary blood flow such as patent ductus arteriosus (PDA) and other atrial and ventricular septal defects may cause congestive heart failure. PDA is a vascular connection that during fetal life bypasses the pulmonary vascular bed and directs blood from the pulmonary artery to the aorta. Defects that involve decreased pulmonary blood (such as tetralogy of Fallot) or obstruction to blood flow out of the heart (such as pulmonary stenosis) typically result in cyanosis. PDA does not cause pulmonary stenosis. A PDA normally closes soon after birth. If the ductus does remain open after birth, the direction of blood flow in the ductus is reversed by the higher pressure in the aorta, so there may not be any signs of the disorder.
A nurse is admitting a newborn to the nursery and learns that forceps were used during delivery. What condition should the nurse assess for in the infant? A. Torticollis B. Facial paralysis C. Fractured clavicle D. Cephalohematoma
Answer: B Rationale: Facial paralysis can occur when the forceps blades compress cranial nerve VII (facial) anterior to the ears. It is usually mild and temporary, lasting only several days. Torticollis is a deformity of the neck not associated with newborns. A fracture clavicle may occur during birth as a result of dystocia, vacuum extraction, or large birth weight. Cephalohematoma is an extravasation of blood from ruptured vessels between the skull bone and its external covering known as the periosteum. The hematoma does not cross over a cranial suture line.
An infant is born to an alcoholic mother. Which assessment finding would the nurse anticipate that would contribute to the finding of fetal alcohol syndrome? A. lethargy B. irritability C. blindness D. unresponsiveness
Answer: B Rationale: Fetal alcohol syndrome (FAS) is a congenital abnormality resulting from excessive maternal alcohol intake during pregnancy. It is characterized by typical craniofacial and limb defects, cardiovascular defects, intrauterine growth restriction and developmental delays. Newborns with FAS are very irritable and difficult to calm and comfort. Seizure activity may also occur. The other answer options A, C, and D are not associated with fetal alcohol syndrome.
Which of the following signs would alert a nurse to withdrawal in the infant of a mother addicted to heroin? A. lethargy and a lack of appetite B. restlessness, irritability, and tremors C. no crying and hypoactive reflexes D. hyperactive reflexes and diaphoresis
Answer: B Rationale: Heroin does cross the placental barrier; therefore the infant is born addicted to heroin and will display signs of withdrawal such as restlessness, irritability, and tremors. The items listed in answer options A, C, and D are not associated with heroin withdrawal.
A neonate weights 8 lb, 1 oz at birth. At age 3 days, the weight has decreased to 7 lb, 12 oz. The nurse should instruct the mother to: A. increase the amount of formula to prevent further dehydration and weight loss B. continue feeding on demand because the noted weight loss is within normal limits C. give additional feedings because the weight loss indicates inadequate caloric intake D. switch to a different formula because the current one is inadequate to maintain weight
Answer: B Rationale: Neonates tend to lose 5% -- 10% of their birth weight during the first few days after birth, mostly because of decreased, but acceptable, nutrition and extracellular fluid loss. Increasing formula volumes and feedings or changing the formula is not necessary in this situation.
What is the best technique for assessing jaundice in a newborn? A. testing capillary refill B. blanching skin on the forehead C. assessing the skin on the palm of the hands D. assisng the skin on the bottom of the feet
Answer: B Rationale: The best tecnique to assess jaundice in the newborn is to apply pressure to a bony area (e.g., forehead and observe the color of the skin before blood returns. Blanched skin is yellow if the infant is jaundiced. The answers in option A, C, and D may determine jaundice; however, they are not as good as applying pressure (blanching the skin) over a bony prominence.
The parents of a newborn question the nurse regarding the blue-black discoloration in the sacral area of their infant. The nurse explains these are known as "Mongolian spots" and: A. indicate a birth defect B. usually fade over time C. result from trauma during delivery D. are indicative of an internal problem
Answer: B Rationale: Monogolian spots are discolorations that appear in the dark-skinned infants and will fade in appearance. They are often mistaken for child abuse. Mongolian spots are not considered a birth defect, do not result from a traumatic delivery, and do not indicate an internal problem.
A nurse is assessing a newborn and and recognizes which of the following as a sign of postmaturity? A. presence of vernix caseosa B. long, brittle fingernails C. fine lanugo hair on the face, shoulders, and back D. creases in the soles of the feet
Answer: B Rationale: The fingernails begin to form around 12 weeks' gestation. By 39--40 weeks, the nails have covered the nailbeds. After 40 weeks, the nails begin to extend and have a long appearance. Presence of vernix caseosa (a cheeselike whitish substance that serves as a protective covering), a fine lanugo hair, and creases in the soles of the feet are all signs of the normal term newborn.
The nurse is assisting a new mother with breast-feeding. The nurse notes that the infant is nursing well when which behaviors are observed? (SELECT ALL THAT APPLY) A. The infants makes a clicking noise B. Swallowing is audible C. The mother reports a pulling sensation on her nipple D. The infants sucks with dimpled cheeks E. The tip of the infant's nose and chin touch the breast
Answer: B, C, E Rationale: When the infant has latched on correctly and is sucking appropriately, swallowing is audible, the mother will report a pulling sensation on the nipple, and the tip of the baby's nose, cheeks, and chin are all touching the breast. If the infant makes a clicking or smacking sound and sucks with dimpled cheeks the infant may be having trouble keeping the tongue out over the lower gum ridge. The jaw may need to be stabilized. If this is not helpful, take the baby off the breast and re-attempt latching.
An infant is born with Down syndrome should be assessed for which condition? A. Clubfoot B. Cleft palate C. Cardiac defect D. Choanal atresia
Answer: C Rationale: Approximately 30% -- 40% of infants born with Down Syndrome have congenital heart defects, typically endocardial cushion defects. Clubfoot, cleft palate, and choanal atresia are all congenital defects. Clubfoot is a deformity in which portions of the foot and ankle are twisted out of normal position. A cleft palate is incomplete closure of the palate resulting in failure of the primary palate to fuse. Choanal atresia is an obstruction of the posterior nares by tissue or bone.
A nurse explains to a new mother reasons for her newborn's cranial molding and determines that the mother needs further instruction when she makes which of the following statements? A. "The molding should disappear within a few days." B. "The molding is caused by an overriding of the cranial bones." C. "The brain may be damaged if the molding doesn't resolve quickly." D. "The amount of molding is related to the amount and length of pressure on the head."
Answer: C Rationale: Brain damage is not directly associated with cranial molding. During vaginal delivery, the cranial bones tend to override when the head accommodates the size of the mother's birth canal. The amount and length of pressure influence the degree of molding, which usually disappears in a few days without any other interventions or long-lasting effects.
A 12-hour-old infant has hemolytic disease of the newborn. What is the most common complication of this disorder? A. respiratory failure B. Liver failure C. Jaundice D. Blindness
Answer: C Rationale: Hemolytic disease of the newborn is caused by incompatibility of maternal and fetal blood types. When the fetal Rh-positive antigens or anti-A or anti-B antigens cross into the maternal circulation, the mother produces anti-Rh, anti-A, or anti-B antibodies. When the maternal anti-Rh, anti-A, or anti-B antibodies cross into the fetal circulation, these antibodies attack the fetal RBCs. The RBC destruction results in release of excess bilirubin, which the fetal or newborn's immature liver cannot metabolize; the result is newborn jaundice. Respiratory failure, liver failure, and blindness are not common complications of hemolytic disease of the newborn when appropriate treatment is provided.
A neonate experiences meconium aspiration at the time of delivery and develops respiratory distress syndrome (RDS). Which nursing diagnosis would be most appropriate for an infant diagnosed with this disorder? A. Risk for Infection B. Risk for Aspiration C. Impaired Gas Exchange D. Dysfunctional Ventilatory Weaning Response
Answer: C Rationale: Impaired gas exchange is the most appropriate nursing diagnosis because meconium aspiration interferes with the exchange of O2 and CO2. Risk for infection is present but is not as high a priority as impaired gas exchange. Risk for aspiration has already occurred. Dysfunctional ventilatory weaning response may be appropriate i the newborn demonstrates difficulty with the ventilatory weaning process
When instructing a new mother about the newborn's need for sensory stimulation, the nurse should explain that the most highly developed sense is the neonate is: A. taste B. smell C. touch D. hearing
Answer: C Rationale: It is believed that the sense of touch is the most highly developed sense at birth. For this reason, neonates respond well to touch. The senses of taste, smell, and hearing are functional in the newborn; however, not the extent of touch.
At the time of delivery, the nurse assigns a newborn an Apgar score at 1 and 5 minutes. THe purpose of this scoring system is to obtain: A. the infant's initial vital signs B. a survey of gross functioning C. an initial assessment of vital functions D. an assessment of mental retardation
Answer: C Rationale: The Apgar score is an initial assessment of vital functions. These include heart rate, respiratory effort, muscle tone, reflex response, and color. The other answer options A, B, and D are not primary purposes of the Apgar score. However, vital signs and gross function are taken into consideration.
A new father observes his newborn infant receiving a vitamin K injection and asks the nurse, "Why did my son need a shot?" The nurse's response should be based on the understanding that infants: A. need vitamin K to stimulate liver maturation B. cannot get enough vitamin K from their feeeings C. have a sterile intestinal tract and cannot synthesize vitamin K D. are often born with hypokalemia, which responds to vitamin K therapy
Answer: C Rationale: There seems to be some controversy as to whether vitamin K should be given, but often it is because the newborn infant cannot synthesize vitamin K due to the lack of intestinal bacteria at birth. The other answer options A, B, and D are incorrect rationales for administration of vitamin K in newborns.
A nurse assesses a newborn with asymmetric gluteal and thigh skinfolds, a left leg shorter than the right, and a clicking sound of the right hip. What condition does this information indicate that the newborn most likely has? A. fractured pelvis B. fractured right leg C. congenital hip dysplasia D. underdeveloped femur
Answer: C Rationale: With congenital hip dysplasia, the hip is not correctly situated or rotating in the socket. The affected leg will appear longer, and a clicking sound can be heard when the leg is moved. The symptoms listed do not describe a fracture pelvis or leg; however a newborn could sustain a fracture as a result of a traumatic birth. An underdeveloped femur is not a newborn condition.
A 48-hour-old infant who is being breast-fed is diagnosed with physiological jaundice and is prescribed phototherapy treatment. Which measure taken by the nurse would enhance bilirubin excretion? A. keeping the infant snugly wrapped B. placing the infant in a quite, darkened area C. providing the infant with additional oral fluids every 3 hours D. encouraging the mother to temporarily suspend breast-feeding her infant
Answer: C Rationale: Phototherapy can cause insensible water loss, thus it is important to assess for dehydration and provide fluids. Proper fluid balance will promote bilirubin excretion. Keeping the infant wrapped in the dark and suspending breast-feedings will not enhance the excretion of bilirubin.
Which observation in a 24-hour-old newbon should be reported to the physician immediately? A. jaundice B. positive Babinski reflex C. heart rate of 130/bpm D. High-pitched crying and arching of the back
Answer: D Rationale: A high-pitched cry and arching of the back (opisthotonos) are cardinal signs of a neurological abnormality. Physiological jaundice occurs in 50% of term infants after the first 24 hours. A serum bilirubin level should be drawn to determine if treatment with phototherapy is necessary. A positive babinski reflex is a normal response in newborns. It is characterized by all the toes hyperextending with dorsiflexion of the big toe. A heart rate of 130 bpm falls within the range.
Which finding would be manifested in an infant with a myelomeningocele? A. clubbed feet and paralysis in the legs and arms B. Obstruction of bowel and impaired bladder function C. Spastic movement of upper and lower extremities D. Impaired bowel and bladder function and paralysis of the legs
Answer: D Rationale: A myelomeningocele is an external sac containing meninges, spinal fluid, and nerves that protrude through a defect in the vertebral column. The nerves of the cauda equina are involved with a myelomeningocele, which results in lower extremity paralysis. Innervation to the anal sphincter and the bladder is decreased, causing incontinence. In myelomeningocele, bowel function may be affected, but it is not associated with obstruction. The upper extremities are not affected by this disorder. In addition, clubfoot is not associated with this disorder.
A nurse should observe for which particular complication in infants who are born breech? A. cyanosis B. fracture hip C. hydrocephalus D. brachial palsy
Answer: D Rationale: Brachial palsy results from the stretching of nerve fibers in the neck, shoulder, and arm when the shoulder is being pulled away from the neck during breech delivery. Cyanosis, fractured hip, and hydrocephalus are not directly associated with breech deliveries.
Compared with an infant born vaginally an infant born via cesarean section is more likely to manifest which condition? A. crib death syndrome B. neurological deficits C. failure to thrive syndrome D. Respiratory distress syndrome
Answer: D Rationale: Research has shown that respiratory distress syndrome (RDS) is more common in infants born by cesarean birth without labor than in those born vaginally. The other answer options A, B, and C are not associated with cesarean births
During assessment the nurse understands that the Moro reflex should disappear by what age in an infant? A. 4 weeks B. 6 weeks C. 2 months D. 4 months
Answer: D Rationale: The Moro reflex is exhibited by the infant when suddenly jarred or a change in equilibrium occurs. This reflex usually disappears by 4 months. If the Moro reflex is still present after the age of 6 months, neurological maturity may be delayed or another neurological disorder may be present. The other answer options A, B, and C are incorrect.
A nurse caring for the newborn of a diabetic mother would give highest priority to assessing for which conditions? A. Hypocapnia B. Hyponatremia C. Hyperglycemia D. Hyperinsulinism
Answer: D Rationale: The infant of a diabetic mother has become accustomed to high levels of glucose in the maternal circulation and therefore makes insulin accordingly. After deliver, the infant's glucose source is withdrawn and the infant is then prone to hyperinsulinism thus manifesting as hypoglycemia. Blood glucose levels should be closely monitored and early feedings are recommended. Hypocapnia and hyponatremia are not associated with newborns of diabetic mothers. Hyperglycemia is a risk, especially if the newborn is receiving parenteral glucose to treat hypoglycemia.
A nursery nurse performs an initial newborn assessment and checks the umbilical cord to identify which normal finding? A. One artery and two veins B. One artery and one vein C. Two arteries and two veins D. Two arteries and one vein
Answer: D Rationale: The umbilical cord consists of two arteries and one vein. In the umbilical cord, the vein provides oxygen and nutrients, and the arteries pump oxygen-depleted blood back to the placenta. The other answer options A, B, and C are incorrect.
A nurse brings a new mother her neonate for the first time approximately 1 hour after the neonate's birth. After checking the identification, the nurse hands the neonate to the mother. Within a few minutes, the mother begins to undress her baby. What should the nurse do?
Anticipate and support the behavior as a normal part of bonding.
The nurse brings a new mother her baby for the first time approximately 1 hour after the baby's birth. After checking the identification, the nurse hands the baby to the mother. Within a few minutes, the mother begins to undress her baby. Which of the following should the nurse do?
Anticipate and support the behavior as a normal part of bonding.
A client who delivered by cesarean birth 3 days ago is bottle-feeding her neonate. While the nurse collects data, the client complains that her breasts are painful, hard, and warm to the touch. How should the nurse intervene?
Apply an elastic bandage to bind the breasts.
A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?
Apply an ice pack to her perineum.
The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?
Apply an ice pack to her perineum.
The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal birth. The nurse should next:
Apply an ice pack to the perineal area.
A client who is breastfeeding reports pain, redness, and swelling in her right breast. Which instruction should the nurse give the client?
Apply moist heat compresses to the right breast
A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate?
Applying gentle pressure to the baby's head as it's delivered
When caring for a client who's a primigravida, the nurse would expect the second stage of labor to last how long?
Approximately 2 hours
The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. The client's English-speaking cousin is acting as a translator for the nurse and client. Which nursing intervention takes priority?
Arranging for a home care nurse to assess the client in her home environment
On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which action is appropriate?
Ask the client to empty her bladder
When completing the morning postpartum assessment, a nurse notices a client's perineal pad is completely saturated with lochia rubra. Which action should be the nurse's first response?
Ask the client when she last changed her perineal pad.
A client who's in active labor is yelling, "Get out of here!" As the nurse enters the client's room, she notices the client's estranged husband in the room. How should the nurse intervene?
Ask the husband to leave or phone security.
A client in labor develops complications and is given general anesthesia. The physician informs the husband that without emergency cesarean delivery his wife and the baby may die. The husband asks the nurse what he should do. How should the nurse respond?
Ask the husband whether he and his wife ever discussed treatment options in the event of an emergency.
A neonate begins to gag and turns a dusky color. What should the nurse do first?
Aspirate the neonate's nose and mouth with a bulb syringe.
When preparing for discharge a 15-year-old primipara who is bottle-feeding her neonate, the nurse instructs the client not to "prop" the bottle while feeding the neonate because this can lead to which of the following?
Aspiration of the formula.
A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which of the following would be the nurse's initial action?
Assess for presence of a full bladder.
A client has delivered twins. Which intervention would be most important for a nurse to perform?
Assess fundal tone and lochia flow
The clinic nurse is assessing a postpartum client's fundus at the umbilicus 2 weeks after giving birth. Which of the following would the nurse include in the client's plan of care?
Assess the client's bleeding flow and color.
On examining a client who gave birth 3 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which actions should the nurse take?
Assess the client's vital signs and palpate the client's fundus
The nurse is caring for a client who just delivered triplets. Which intervention by the nurse is most important?
Assessing fundal tone and lochia flow
Which care intervention is appropriate for the fourth stage of labor?
Assessing lochia and the location and consistency of the fundus
Using the acronym COAT or TOCA, what is the nurse assessing and what are important to ask the client?
Assessing the amniotic fluid after the bag of membranes has been broken. • C : Color (Clear, Blood Tinged, Green Meconium) • O : Odor (Possible Infection) • A : Amount (Trickle (scant), Copius, Moderate) • T : Time (When? To prevent infection labor within 24 hrs.)
A registered nurse is staff-shared to the maternal-neonatal unit where she has never worked before. How can this nurse be best employed?
Assign her a client care assignment in the postpartum unit
The nurse understands that measures are necessary to contain health care costs. Which intervention demonstrates effective resource management?
Assigning the nurse's aide to deliver meal trays and to stock rooms; assigning the licensed practical nurse to collect assessment data
A client experiencing hard, steady labor is crying and asking for something for pain. Her medical record shows that she doesn't tolerate typically prescribed pain medications. Which nonpharmacologic intervention might be helpful to this client?
Assisting the client into another position and providing a gentle backrub
A client in the early stages of active labor wants to get out of bed and walk around the room. Which action by the nurse is best?
Assisting the client to ambulate in the room
When caring for a client during the second stage of labor, which action would be most appropriate?
Assisting the mother with pushing
After delivering a neonate, a client delivers the placenta. At this time, where does the nurse expect to palpate the uterine fundus?
At the midline, 0.4" to 0.8" (1 to 2 cm) below the umbilicus
A postpartum client is receiving anticoagulant therapy for deep vein thrombophlebitis. Discharge teaching should include which instruction?
Avoid over-the-counter preparations containing aspirin.
A postpartum client is receiving anticoagulant therapy for deep vein thrombophlebitis. Discharge teaching should include which instruction?
Avoid over-the-counter salicylates.
9. A 22-year old client with a history of drug abuse delivered a low-birth-weight baby who is experiencing withdrawal symptoms. What is the priority action the nurse should take? A. Dress the infant in loose-fitting clothing B. Place the infant in a quiet area of the nursery C. Place the infant near to the nurses' station D. Withhold medications until liver function improves
B. Place the infant in a quiet area of the nursery Rationale: The infant experiencing drug withdrawal should be placed in a quiet area of the nursery to minimize stimuli. The nurses' station is typically not a quiet area. The infant should be swaddled (wrapped tightly) to prevent his stimulating himself by moving. Medications should be administered as needed.
4. What is a common adverse effect of phototherapy in the neonate? A. Kernicterus B. Watery stools C. Positive Coombs test D. Polyuria
B. Watery stools Rationale: Watery stools result from the increased excretion of bilirubin. Kernicterus is a complication of jaundice, not phototherapy. Polyuria is not a complication of phototherapy
The nurse is about to give a full-term neonate his first bath. How should the nurse proceed?
Bathe the neonate only after his vital signs have stabilized.
A client is progressing through the first stage of labor. Which finding signals the beginning of the second stage of labor?
Bearing-down reflex
A client in labor is receiving oxytocin (Pitocin). During oxytocin therapy, why must the nurse monitor the client's fluid intake and output closely?
Because oxytocin causes water intoxication
A client and her neonate have a blood incompatibility, and the neonate has had a positive direct Coombs' test. Which nursing intervention is appropriate?
Because the woman has been sensitized, don't give RhoGAM.
The nurse is preparing to administer a rubella vaccine to a postpartum client before discharge. Which of the following should the nurse caution the client to avoid?
Becoming pregnant for at least 1 month
A nurse is assessing a client on the sixth postpartum day. Which condition requires prompt nursing action?
Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery
During labor, a client asks the nurse why her blood pressure must be measured so often. Which explanation should the nurse provide?
Blood pressure reflects changes in cardiovascular function, which may affect the fetus.
A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary health care provider?
Blurred vision and headache
A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift?
Bottle- or breastfeeding preference
The licensed practical nurse is delegating responsibilities to a certified nurse's aide on a busy postpartum unit. Which task can be appropriately delegated to the nurse's aide?
Bottle-feeding a 24-hour-old neonate
A client is resting comfortably 4 hours after delivering her first child. When measuring her heart rate, the nurse expects which normal finding?
Bradycardia
Which finding in a neonate suggests hypothermia?
Bradycardia
Which client action should alert a nurse to a potential problem in a client with mastitis?
Breast-feeding every 6 hours
Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation?
Breech position
A client has progressed through the first stage of labor. Which data collection finding suggests she's in the transition to the second stage?
Bulging of the vaginal introitus
The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful?
Burping the baby frequently
A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?
By positioning the neonate so that the head remains still
A client is admitted to the labor and delivery area. How can the nurse most effectively determine the duration of the client's contractions?
By timing the period from the onset of uterine tightening to uterine relaxation
5. A 2-day old neonate has a temperature of 101oF, axillary. The nurse knows that the physician will most likely prescribe which tests? A. Urinalysis B. Blood culture and throat culture C. Cerebro-spinal fluid (CSF) culture, blood culture and CBC D. CBC and arterial blood gas
C. Cerebro-spinal fluid (CSF) culture, blood culture and CBC Rationale: The newborn is exhibiting a sign of sepsis. The physician will most likely prescribe cerebrospinal fluid and blood cultures as well as a CBC to determine the cause. A urinalysis would indicate only the presence of a urinary tract infection. Arterial blood gases are not indicated at this time.
10. A client who has abused alcohol during her pregnancy has a baby with Fetal Alcohol Syndrome (FAS). The nurse looks for which of these findings during assessment? A. Hydrocephaly, malar prominences, large upper lip B. Prominent nasal bridge, flat midface and iindistinct philtrim C. Microcephaly, flattened nasal bridge, indistinct philtrim D. Large eyes, large upper lip and microcephaly
C. Microcephaly, flattened nasal bridge, indistinct philtrim Rationale: The craniofacial abnormalities associated with FAS include: microcephaly, small eyes 9or short palpebral fissures, thin upper lip, flat midface and indistinct philtrim.
8. A baby boy is born 8 weeks prematurely. At birth he has no spontaneous respirations but is resuscitated successfully. Within several hours he develops nasal flaring, grunting, tachypnea and retractions. He is diagnosed with respiratory distress syndrome, intubated and put on a respirator. What would be a priority intervention of the nurse to prevent retinopathy of prematurity? A. Keep his body temperature low B. Cover his eyes while receiving oxygen C. Monitor partial pressure of oxygen (PaO2) D. Humidify the oxygen
C. Monitor partial pressure of oxygen (PaO2) Rationale: Monitoring the PaO2 levels and reducing the oxygen concentration to keep PaO2 levels within normal limits prevents the retinopathy of prematurity. Covering the infant's eyes or increasing the humidity does not reduce the incidence of retinopathy of prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so the baby's respiratory distress is not aggravated.
7. A newborn's mother had uncontrolled gestational diabetes mellitus during her pregnancy. She delivers an infant at 38 weeks. What priority intervention would the nurse make in the first 24 hours with this infant? A. Administer insulin subcutaneously to the baby B. Administer a bolus of glucose IV C. Provide frequent early feeds with formula D. Avoid oral feedings
C. Provide frequent early feeds with formula Rationale: The infant of a diabetic mother is often hyperglycemic at birth because of the high maternal glucose levels. At birth, the abrupt withdrawal of maternal glucose coupled with high newborn insulin levels can cause severe hypoglycemia. Frequent early formula feedings can prevent hypoglycemia. Insulin should not be administered since the infant of a diabetic mother is at risk for hypoglycemia. If glucose is given, IV, it should not be given but it should be administered over time.
6. A term neonate's mother has blood type O-. The baby's blood type is A+. Which of the following would be least likely if the baby developed hemolytic disease? A. Lethargy or irritability B. Signs of kernicterus C. Weight loss > 10% D. Poor feeding patterns, including vomiting
C. Weight loss > 10% Rationale: Although the weight loss is of concern, the most important assessments would address the problem of rising bilirubin in the baby's blood. Infants who develop severe jaundice as a result of a blood incompatibility show lethargy, irritability and poor feeding. If bilirubin levels are high enough to cross the blood-brain barrier (usually ≥ 20 mg), the baby is at risk for neurological impairments due to permanent cell damage (kernicterus).
During a busy shift on the labor and delivery unit, a nurse failed to document whether she administered a medication to aid uterine contractions. The nurse who's currently caring for the client is asked whether the medication has been successful. She explains that she hasn't been monitoring its effectiveness because she didn't know that the medication was administered. Which intervention by the nurse is best?
Call the nurse at home to inquire whether she gave the medication, then ask the client about the contractions while the physician is present.
A client is admitted to the labor and delivery area. The nurse-midwife checks for fetal descent, flexion, internal rotation, extension, external rotation, and expulsion. What do these terms describe?
Cardinal movements of labor
A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which action should be included in the plan of care?
Carefully titrating the oxytocin based on the client's pattern of labor
A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 ml. The nurse palpates the fundus 2 fingerbreadths above the umbilicus and off to the right side. What should the nurse do first?
Catheterize the client.
Which complication may be indicated by continuous seepage of blood from the vagina of a postpartum client when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus?
Cervical laceration
A client with active genital herpes is admitted to the labor and delivery area during the first stage of labor. Which type of birth should the nurse anticipate for this client?
Cesarean
After receiving the shift report, the nurse realizes that she should monitor her postpartum client closely for puerperal infection. Which factor alerted the nurse to the client's risk for this complication?
Cesarean birth
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
Change the client's position.
A client in the second stage of labor experiences membrane rupture. Which intervention by the nurse is appropriate?
Check for a prolapsed cord.
A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after childbirth. Which of the following priorities outcome criteria should the client achieve?
Client voids more than 30 mL/hour without urinary retention beginning 1 hour after birth.
The nurse is beginning a shift caring for a group of postpartum clients. Which of the following clients would be a priority for the nurse to see first?
Client who states she has pain in the left calf
A clinical pathway is guiding care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. Which outcome should be achieved within the next 8 hours?
Client will demonstrate ability to bottle-feed the neonate.
A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?
Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."
Express a small amount of breast milk
Close all of the doors on the unit
The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm?
Close all of the doors on the unit.
Certain drugs used during the postpartum period may affect blood pressure. Which drug would decrease a postpartum client's blood pressure?
Codeine phosphate
The nurse-midwife determines that a client is in the second stage of labor and may start pushing. What marks the beginning of the second stage, and what marks the end?
Complete cervical dilation; delivery of the neonate
Staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner?
Conduct a class for clients who require the same discharge teaching
A client who tested positive for the human immunodeficiency virus (HIV) is in active labor. During delivery, blood splashes and contaminates the care area. Which action should the nurse take?
Contact housekeeping and ask them to clean the area because it has been contaminated by blood-borne pathogens.
A 30-year-old woman, G 4, P 4, has given cesarean birth to a healthy term female neonate following an abnormal fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's Foley catheter and observes that the client's urine is slightly red tinged. Which of the following should the nurse do next?
Contact the client's physician for further orders.
A client who's in labor and who attended natural childbirth classes is asking for something for pain. What should the nurse do?
Contact the physician and support the client until something can be ordered for pain.
A 30-year-old multigravida with prolonged rupture of membranes is diagnosed with endometritis 36 hours after birth of a viable neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client's temperature is 100°F (37.8°C), pulse rate is 124 bpm, and respirations are 24 breaths/minute. The nurse should:
Contact the primary care provider
While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8° F (37.2° C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:
Continue to monitor the client's vital signs
While observing a new mother interact with her first baby, the nurse observes that the client appears hesitant to care for the neonate. Which of the following actions would be most important for the nurse to do?
Continue to provide praise and support to the client
A nurse is performing an assessment on a postpartum client. The assessment reveals that the fundus is firm. This data indicates which condition?
Contraction of the uterus
During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin (Pitocin). When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?
Contractions will be stronger and more uncomfortable and will peak more abruptly.
What is the definition of Labor?
Contractions with cervical change.
Six hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?
Cool isolette walls
Which practice should a nurse recommend to a client who has had a cesarean birth?
Coughing and deep-breathing exercises
Which practice should a nurse recommend to a client who has had a cesarean delivery?
Coughing and deep-breathing exercises
Which intervention takes priority when caring for a neonate immediately after birth?
Covering the neonate's head with a cap
1. A nurse in the newborn nursery is preparing to collect a blood specimen for a test for Phenylketonuria (PKU) on a newborn. Which baby is a candidate for this test? A. A baby that is breast-fed and is being discharged within 24 hours of birth B. A baby that is 1-day old and formula-fed C. A 3-day-old baby that has been fed IV since birth D. A 2-day old baby that is being breast fed
D. A 2-day old baby that is being breast fed Rationale: To test for PKU, an infant must have ingested sufficient phenylalanine through at least 2 days of formula or breast feeding. A baby who has received IV fluids since birth will have to have formula or breast milk intake for at least 48 hours to be tested. An infant discharged within 24 hours will have to come to the pediatrician's office for a PKU test after ingestion of breast milk or formula for 48 hours.
3. An alarm signals that a newborn's security identification band needs attention. The nurse comes to the room and notes that the identification bands are no longer on the infant. Which action should the nurse take next? A. Reprimand the parents for allowing the bands to come off B. Replace the identification bands C. Obtain the baby's footprints and compare them to the ones collected at birth D. Compare the number on the baby's identification bands with the mother's identification band and then reattach the bands to the baby's extremities
D. Compare the number on the baby's identification bands with the mother's identification band and then reattach the bands to the baby's extremities Rationale: The nurse should immediately compare the numbers on the baby's bracelets with those on the mother's bracelet and then reattach the bracelets to the baby. The nurse is not qualified to compare footprints and reprimanding the parents would be harmful to the nurse-patient relationship. Replacing the bands without verifying identification would be irresponsible.
The nurse is assessing a postpartum client who has lochia serosa (old blood, serum, leukocytes, and tissue debris). When the client asks the nurse how long to expect this type of bleeding, what should the nurse's response be?
Days 3 to 10 postpartum
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?
Decreased blood volume in the vascular system.
The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents?
Deficient knowledge related to apneic episodes
What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum?
Dehydration
Which sign of grieving is dysfunctional in a client 3 days after a perinatal loss?
Denial of the death
A client delivers a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's husband seems withdrawn and barely speaks to the staff when visiting his child in the NICU. His behavior indicates that he's in which stage of grief?
Depression
An unmarried, unemployed young mother is being discharged with her infant, accompanied by a friend. After referrals to social services and home health care, which assessment is most important to make?
Determining whether the temperature in the client's home is kept around 70° F (21.1° C) during the day
A client with diabetes mellitus is in labor. She tells the nurse she has had trouble controlling her blood glucose level recently. She says she didn't take her insulin when the contractions began because she felt nauseous; about 1 hour later, when she felt better, she ate some soup and crackers but didn't take insulin. Now, she reports increased nausea and a flushed feeling. The nurse notes a fruity odor to her breath. What do these findings suggest?
Diabetic ketoacidosis
A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action?
Discuss the unit's policy with the charge nurse.
During a staff meeting, the nurse-manager shares the results of the most recent client satisfaction survey. More than half of all clients who responded feel the nurses are less than empathetic toward women in labor. Which action should the nurse-manager and her staff take to address this issue?
Discuss ways to improve their approach to clients in labor, then hold weekly progress meetings.
A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction?
Discussing the purpose of the vaccine and providing the client with written information
A client confides that she's estranged from the abusive father of her infant. Which nursing intervention would ensure client confidentiality?
Discussing with the client whether she'd like to use another name while hospitalized
Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, observation of which of the following should alert the nurse to the development of a possible side effect?
Dizziness.
While caring for a healthy female neonate, the nurse notices red stains on the diaper after the baby voids. Which of the following should the nurse do next?
Do nothing because this is normal.
A primipara has given birth to her baby, with labor, birth, recovery, and the postpartum period in the same hospital room. The client had a midline episiotomy and epidural anesthesia. While assessing the client's pulse 30 minutes after the birth, the nurse determines that the pulse rate is 60 bpm. The nurse should:
Do nothing because this pulse rate is considered a normal finding.
A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next?
Document these expected behaviors of the taking-in period.
While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client's urine has two small blood clots in the measuring container. Which of the following should the nurse do next?
Document this observation as a normal finding.
Which intervention should the nurse perform as soon as possible when caring for a 21-week-old anencephalic neonate?
Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets.
A baby born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation?
Drying him thoroughly after a bath
At which of the following times should the nurse anticipate assisting a client to breast-feed her neonate?
During the neonate's first period of reactivity.
While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
Dyspnea
During assessment for admission to the labor and delivery area, a client and her husband ask the nurse whether their sons, ages 8 and 10, can witness the childbirth. Before answering this question, the nurse should consider which guideline?
Each child attending the childbirth should have a separate support person.
A client in labor tells the nurse-midwife that she feels a strong urge to push. Physical examination reveals that her cervix is not completely dilated. The nurse-midwife tells her not to push yet. What is the rationale for this instruction?
Early pushing may cause edema and impede fetal descent.
During a childbirth education class, a nurse-educator discusses pain control techniques used during labor and delivery. Which technique most effectively helps a client cope with the pain of uterine contractions?
Effleurage and other cutaneous stimulation
Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for cystitis?
Emptying the bladder every 2 to 4 hours while awake.
A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful?
Encourage the client to see, touch, and hold the dead neonate.
Which action should the nurse take to promote the descent of the fetus's presenting part?
Encourage the client to void every 2 hours.
The nurse has assisted a multigravida with a precipitous birth of a viable neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication?
Encourage the mother to breast-feed the infant.
Which intervention should be included in the plan of care for a client with an episiotomy on the third postpartum day?
Encourage the use of sitz baths
When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is appropriate?
Encouraging increased fluid intake
The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate?
Enlarged breast tissue
The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.
A client whose blood type is A− gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important?
Ensuring that the client understands the procedure and signs a consent for the vaccination
A client who admits she uses heroin gives birth to a neonate at 32 weeks' gestation. Which neonatal assessment is most important for the nurse to perform?
Evaluation for signs of drug withdrawal
A client is in the second stage of labor. During this stage, how frequently should the nurse assess her uterine contractions?
Every 15 minutes
The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first?
Explore her own personal beliefs and feelings about contraception.
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following?
Express a small amount of breast milk
After pitocin has been administered, how often should the fetal monitoring be checked? How often should vitals be taken? How often should temperature be checked?
FHR/FT : Q15min. VS : Q30min Temp. :Q4hrs (if fever Q1hr.)
A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which of the following?
Fainting
The nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should expect which nursing diagnosis in the client's plan of care?
Fear related to a potentially difficult childbirth
The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary?
Fetal heart rate of 80 beats/minute
A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?
Fetal heart rate variability within an acceptable range
A 28-year-old woman gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus?
Firm, at the level of the umbilicus
A primiparous client, 20 hours after giving birth, asks the nurse about starting postpartum exercises. Which of the following would be most appropriate to include in the nurse's instructions?
Flex the knees while supine, then inhale deeply and exhale while contracting the abdominal muscles.
When using a Pavlik harness on a neonate with developmental dysplasia of the hip, the nurse should ensure that the affected hip is in which position?
Flexed and abducted
While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest?
Football hold.
When performing a comprehensive fundal check during a postpartum assessment, a nurse evaluates which fundal state?
Fundal consistency, location, and height
Which assessment finding in a postpartum client requires further nursing assessment?
Fundus slightly to right; 2 cm above umbilicus on postpartum day 2
A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?
Fundus two fingerbreadths above the umbilicus
The nurse is preparing to perform a physical examination on a postpartum client. Which statement best explains why the nurse must wear gloves during this examination?
Gloves are required for standard precautions.
A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?
Gloves are required for standard precautions."
A woman who is breast-feeding tells the nurse that she plans to return to work in 6 months and will probably wean her baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" The nurse should instruct the client about which of the following?
Gradual decrease in milk supply as the baby nurses less.
Which of the following should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate?
Gradually eliminate one feeding at a time.
Four clients each gave birth 12 hours ago. Which one would most likely suffer complications after birth?
Gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl
When assessing a client who has just delivered a neonate, the nurse finds that the fundus is boggy and deviated to the right. What should the nurse do?
Have the client void.
Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which complaints?
Headache, blurred vision, and facial and extremity swelling
Which assessment requires immediate action by a nurse in a client 22 hours following a cesarean delivery?
Heart rate of 132 beats/minute and blood pressure of 84/60 mm Hg
Which assessment of the mother should be made in the immediate postpartum period (first 2 hours)?
Height of fundus
A client who comes to the emergency department in the early stages of labor is admitted to the labor and delivery unit. The nurse observes that the client hasn't recently bathed or changed her clothes. What should the nurse do to help this client?
Help the client to undress and suggest a quick bath to freshen up.
(SELECT ALL THAT APPLY) A client is at risk for which postpartum complication during the fourth stage of labor?
Hemorrhage
In the fourth stage of labor, a full bladder increases the risk of which postpartum complication?
Hemorrhage
The physician orders an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?
Hemorrhage
A pregnant client is very upset when she hears that her TORCH panel has returned positive. She is distraught and says, "This means the baby has HIV!" The nurse replies that the H in TORCH represents which disorder?
Herpes simplex virus
Which assessment should be performed routinely in the postpartum client?
Homans' sign
A client is receiving oxytocin (Pitocin) to treat postpartum hemorrhage. When planning the client's care, the nurse anticipates monitoring for which common adverse reactions?
Hypertension and tachycardia
A client in labor receives epidural anesthesia. The nurse should assess carefully for which adverse reaction to the anesthetic agent?
Hypotensive crisis
When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis takes highest priority at this time?
Hypothermia related to heat loss
A nurse demonstrates infant bathing to a primiparous client. Which statement by the client indicates a need for additional teaching?
I have all kinds of pretty, scented soaps and lotions to bathe the baby with."
A 15-year-old unmarried primiparous client is being cared for in the hospital's birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which of the following responses would be most appropriate?
I'll bring the baby to you for feeding."
A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate positive attachment behaviors upon discharge. Which intervention would be least effective in accomplishing this goal?
Identify strategies to prevent difficulties in parenting
Which of the following options is a contributory factor to thermoregulation in a preterm neonate?
Immature central nervous system (CNS)
A client with Rh isoimmunization delivers a neonate with an enlarged heart and severe, generalized edema. Which nursing diagnosis is most appropriate for this client?
Impaired parenting related to the neonate's transfer to the intensive care unit
A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn?
Increased amounts of vernix
During the active phase of the first stage of labor, a client undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority?
Ineffective tissue perfusion (cerebral) related to cord compression
The nurse-manager overhears a nurse tell a client, "If I were you, I'd ask the doctor for something for pain; you shouldn't have to suffer during labor." How should the nurse-manager respond to the nurse's comment?
Inform the nurse that she'd like to speak with her, then discuss the inappropriateness of her comment in a private location.
A client in the early stage of labor states that she has a thick, yellow discharge from both of her breasts. Which action by the nurse is most appropriate?
Informing the client that the discharge is colostrum, which is a normal finding
A neonate born 30 hours after rupture of membranes has an axillary temperature of 100.8° F (38.2° C). Which intervention should the nurse employ?
Instruct the family to keep the infant in the mother's room until culture results are available.
A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be effective for the couple at this time?
Instruct the husband on touch, massage, and breathing patterns.
Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following steps would be contraindicated when caring for this client?
Instructing the client to use two or more peripads to cushion the area
The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety?
Instructing the mother to notify staff when she showers to avoid leaving the infant unattended
The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)?
Intrauterine fetal death
During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?
It should begin before conception and end 3 months after childbirth
During an annual checkup, a client tells the nurse that she and her husband have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?
It should begin before conception and end 3 months after delivery.
Which characteristic of lochia should a nurse expect in a client two weeks postpartum?
It's creamy white to brown, contains decidual cells, and may have a stale odor
The nurse is caring for a diabetic postpartum client who has developed an infection. The nurse is aware that infections in diabetic clients tend to be more severe and can quickly lead to complications. For which complication should the nurse assess this client?
Ketoacidosis
Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process?
Kissing, embracing, and caring for the infant
In the maternal attachment process, which statement best describes the anticipated actions in the taking-hold phase?
Kissing, embracing, and caring for the neonate
The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?
Large, immature liver
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?
Latent phase
A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Into what position should the nurse assist the client?
Left lateral
An RH-positve client delivers a 6 lb, 10 oz neonate vaginally after 17 hours of labor. Which condition puts this client at risk for infection?
Length of labor
As a postpartum client adapts to her maternal role, she progresses through several phases. During which phase does she begin to accept the neonate as a separate individual?
Letting-go phase
On her 3rd postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What do these findings suggest?
Localized infection
On a client's first postpartum day, the nurse assesses the client's vaginal discharge as dark red and containing shreds of decidua and mucus. What term should the nurse use in her nurse's notes to describe the discharge?
Lochia rubra
The nurse is caring for a postpartum client who develops preeclampsia. Which medication should the nurse expect to administer?
Magnesium sulfate
Which of the following would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate?
Maintain eye contact while talking to the baby.
Which intervention should be included in the safety plan for the maternal-infant unit?
Making sure that the spouse or significant other wears an identification band
During the fourth stage of labor, the nurse notes that the client's fundus is boggy and located above the umbilicus. How should the nurse intervene?
Massage the client's fundus.
A nurse is assessing the fundus of a postpartum client and finds that the fundus is boggy? Which action should the nurse take first?
Massage the fundus
In performing an assessment of a postpartum client 2 hours after delivery, a nurse notices heavy bleeding with large clots. Which response is most appropriate initially?
Massaging the fundus firmly
On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?
Massaging the uterus gently
After admission to the labor and delivery area, a client undergoes routine tests, including a complete blood count, urinalysis, Venereal Disease Research Laboratory test, and gonorrhea culture. The gonorrhea culture is positive, although the client doesn't have signs and symptoms of this disease. What is the significance of this finding?
Maternal gonorrhea may cause an eye infection in the neonate.
During labor, a primigravid client receives epidural anesthesia, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?
Maternal hypotension
Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breastfeeding?
Medications may be excreted in breast milk to the nursing neonate
As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response?
Medroxyprogesterone needs to be administered every 12 weeks
When caring for a client who has had a cesarean section, which of the following actions is appropriate?
Monitoring pain status and providing necessary relief
Which of the following is the primary reason for putting breast-feeding neonates to the breast immediately after delivery?
Most neonates are alert immediately following birth and are ready to nurse.
Which response is most appropriate for a mother with diabetes who wants to breastfeed but is concerned about the effects of breastfeeding on her health?
Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.
Which condition should the nurse look for in a client's history that may explain an increase in the severity of afterpains?
Multiple gestation
On the first postpartum day, the nurse instructs a primipara who has given birth to a term neonate about the neonate's senses. Which of the following statements by the mother indicates successful teaching?
My baby has very good peripheral vision and can see shapes."
The nurse assesses a 1-day-old neonate. Which finding indicates that the neonate is experiencing respiratory distress?
Nasal flaring
Which sign indicates respiratory distress in a neonate?
Nasal flaring
During labor, a client demonstrates signs of fatigue and possible fetal distress. How should the nurse intervene?
Notify the charge nurse and prepare to assist her with necessary interventions.
A multiparous client at 24 hours postpartum demonstrates a positive Homan's sign with discomfort. The nurse should:
Notify the client's physician immediately
When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take?
Notify the physician
When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take?
Notify the physician.
A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to do which of the following?
Observe individuals in the area for large bags or oversized coats.
The nurse is assigned to care for two mothers and their infants. One mother tested positive for group B streptococcus infection and her infant has been running a low temperature of 97.4° F (36.3° C). Which precaution should the nurse take while waiting for the physician to evaluate the infant?
Observe standard precautions and place the infant of the infected mother in a warmer inside the mother's room.
A licensed practical nurse (LPN) who typically works in the neonatal intensive care unit is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to stock rooms, which is typically the responsibility of a nurse's aid. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take?
Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data.
Which measure included in the care plan for a client in the fourth stage of labor requires revision?
Obtain an order for catheterization to protect the bladder from trauma
Three hours after birth, a client becomes weak and dizzy as she attempts to ambulate for the first time. The client's hemoglobin level at the end of pregnancy was 10.4 g/dl. Two hours later she asks to use the bathroom. Which nursing intervention is the top priority?
Obtaining the assistance of a second nurse before attempting to assist the client with ambulation
For a client who's moving into the active phase of labor, the nurse should include which of the following as the priority of care?
Offer support by reviewing the short-pant form of breathing.
A client in active labor is sweating profusely and has minimal urine output. How should the nurse intervene?
Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output.
A client is at the end of her 1st postpartum day. When assessing her uterus, the nurse expects to find the top of the fundus at the midline and at which position?
One fingerbreadth below the umbilicus
A nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
One fingerbreadth below the umbilicus
During the early postpartum period, a nurse is evaluating several clients' attachment to their neonates. Which client is the highest priority for the nurse?
One whose parent died recently
A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?
Orange juice.
A client needs to void 3 hours after a vaginal delivery. Which risk factor necessitates assisting her out of bed?
Orthostatic hypotension
A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following?
Overdistention of the uterus from hydramnios.
A primiparous client who is beginning to breastfeed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with:
Passive immunity from maternal antibodies
A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate?
Performing fundal massage
Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which of the following conditions should the nurse assess further?
Perineal lacerations.
The nurse wraps an infant in two blankets and places a hat on his head. His axillary temperature is 97.2° F (36.2° C). After 30 minutes, his axillary temperature is 97.4° F (36.3° C). How should the licensed practical nurse (LPN) intervene?
Place the infant under a warmer and notify the registered nurse.
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage?
Placenta previa
Several minutes after a vaginal delivery, the nurse observes blood gushing from the client's vagina, umbilical cord lengthening, and a globular-shaped uterus. The nurse should suspect which condition?
Placental separation
A 25-year-old primiparous client who gave bith 2 hours ago has decided to breastfeed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
Placing as much of the areola as possible into the baby's mouth
A client had a spontaneous vaginal delivery after 18 hours of labor. Her excessive vaginal bleeding has now become a postpartum hemorrhage. Immediate nursing care of this client should include which intervention?
Placing the client in Trendelenburg's position
A client just had twins. Twin "A" weighs 2,500 g (5 lb, 8 oz), and Twin "B" weighs only 1,900 (4 lb, 3 oz). In addition to routine nursing care, the physician has ordered that Twin "B" be kept in an isolette to help maintain his temperature. The nurse might suggest which of the following interventions instead of using an isolette to maintain the baby's temperature?
Placing the twins in the same crib so the larger baby can keep the smaller baby warm
While discharging a neonate, the nurse notices that the parents have placed the infant in a child car seat. Which action takes priority?
Pointing out that an infant car seat is safest and arranging for them to rent one
During a home visit to a breastfeeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?
Position the baby with the entire areola in the baby's mouth.
A client is 24 hours postpartum. The nurse anticipates that the client's body is returning to homeostasis. Which assessment finding requires immediate intervention?
Positive Homans' sign
The nurse is assessing a 6-week postpartum client in the obstetrician's office. In the exam room, the nurse asks the client how she's feeling. The client bursts into tears and reports she can barely get out of bed to dress, is crying most of the time, and feels like a failure. The nurse suspects the client is experiencing which condition?
Postpartum depression
In a client one week postpartum with retained placental fragments, which finding should alert a nurse of a common complication?
Postpartum hemorrhage
When checking a client 1 hour after vaginal delivery, the nurse notes blood gushing from the vagina, pallor, and a rapid, thready pulse. What do these data collection findings suggest?
Postpartum hemorrhage
Which complication is associated with magnesium sulfate therapy?
Postpartum hemorrhage
Which complication should a nurse assess for in a client with type 1 diabetes mellitus whose delivery was complicated by polyhydramnios and macrosomia?
Postpartum hemorrhage
When caring for a neonate, what is the most important step the nurse can take to prevent and control infection?
Practicing meticulous hand washing
The nurse evaluates the mothering skills of an adolescent primigravida changing her baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which of the following?
Praise and encouragement.
When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which of the following information?
Pregnancy should be avoided for 3 months after the immunization.
A client who's being admitted to labor and delivery has the following data collection findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time?
Preparing for immediate delivery
Variable decellerations in fetal heart monitor indicates what?
Pressure on the cord causing circulation problems. • Prolapsed Cord • Fetus positioned on cord • Insufficient profusion to fetus
A client takes a hormonal contraceptive to prevent pregnancy. The nurse should instruct her to use an alternative contraceptive method when receiving which drug concomitantly?
Primidone
While preparing a client for a postpartum tubal ligation, the nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse is best?
Privately discussing with the client her understanding of the procedure
When a pregnant client arrives at the hospital and is taken to triage to determine what stage of labor she is in, the nurse gets a urine sample immediately, what is being tested for and what are the implications?
Protein : Hypertention Nitrates : Infection Ketones : Renal Problems and Glucose (Diabetic?)
To ensure that the breast-feeding neonate's weight loss remains within the expected parameter of 5% to 10%, the nurse should initially establish which of the following types of feeding schedules?
Provide feeding on demand.
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a baby boy. Which priority intervention should be included in the plan of care for the baby during his first 24 hours?
Provide frequent early feedings with formula.
A 23-year-old primigravida client is in the active stage of labor. She and her husband have been using breathing techniques. The husband asks whether he can do anything more to help his wife during labor. What should the nurse suggest?
Provide helpful distractions.
During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul-smelling and she has had chills. During palpation of the uterus, the client indicates that she is very sore. The nurse should further assess the client for:
Puerperal infection
A client who is breast-feeding her infant is experiencing breast engorgement. The nurse suggests breast pumping to relieve the breast engorgement. Which instruction should the nurse provide?
Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if she's awake.
When coaching a client to push, the nurse should encourage her to use which technique?
Pushing when she feels like pushing
If there has been a SROM or AROM, how often should the nurse take vital signs?
Q 2hrs.
Six clients are in active labor in the labor and delivery unit. Four additional clients in the early stages of labor were just admitted to the unit. There are three registered nurses (RNs) and two licensed practical nurses (LPNs) assigned to the unit this shift. Which client care assignment provides the best care for these clients?
RNs should be assigned to those in active labor and LPNs should be assigned to those in the early stages of labor.
Which physiological response is considered normal in the early postpartum period?
Rapid diuresis
During labor, a client greatly relies on her husband for support. They previously attended childbirth education classes, and now he's working with her on comfort measures. Which nursing diagnosis would be appropriate for this couple?
Readiness for enhanced family coping related to participation in pregnancy and delivery
A postpartum client is ready for discharge. During discharge preparation, the nurse should instruct her to report which of the following to her primary health care provider?
Redness, warmth, and pain in the breasts
A client admitted with preeclampsia complains of a headache. When caring for a client with preeclampsia, which action is a priority?
Reducing visual and auditory stimulation
A client in active labor believes in a holistic approach to health care. Which intervention might be useful to the client during labor?
Reiki
The nurse is caring for a multiparous client after vaginal birth of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to:
Relate to each twin individually to enhance the attachment process
Relationship of the fetus's presenting part to the mother's pelvis
Relationship of the fetus's presenting part to the mother's pelvis
A 41-year-old multipara client had a spontaneous vaginal delivery of an 8-lb (3,629-g) baby 3 hours ago. The nurse collects the following data: "Fundus firm, three fingerbreadths above the umbilicus and deviated to the right. Perineal pad saturated after 20 minutes." Which nursing intervention by the licensed practical nurse (LPN) is best?
Reminding the client to void and helping her to the bathroom
When caring for a client who has had a cesarean birth, which action by a nurse requires intervention?
Removing the initial dressing for incision inspection
To obtain a good monitor tracing on a client in labor, the mother lies on her back. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which of the following should be the nurse's first action?
Reposition the client to her left side.
A client with a first-degree tear and swollen perineum is 28 hours postpartum when she requests assistance with her first sitz bath. Which intervention by the nurse is necessary at this time?
Requesting that the client call for assistance to walk back to bed when she's finished with the sitz bath
A female neonate born by elective cesarean section to a 25-year-old mother weighs 3,265 g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of the following?
Respiratory distress due to lack of contractions
Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?
Rewarm the neonate gradually.
The nurse is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client?
Risk for deficient fluid volume related to hemorrhage
At birth, a neonate weighs 7 lb, 3 oz. When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should expect which nursing diagnosis to be added to the plan of care?
Risk for injury related to hyperbilirubinemia
A laboring client in transition phase is 8 cm dilated and feels the urge to push. What are the risks to the mom and what is the nursing intervention?
Risk of tearing perinium when <10cm dialted • Use open glottis, short breaths when feeling the urge to push.
A breast-feeding baby will turn his head toward the mother's breast in a natural instinct to find food. What is the name of this reflex?
Rooting reflex
Lochia normally progresses in which of the following patterns?
Rubra, serosa, alba
A woman who has given birth to a healthy baby is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?
Saturating a pad in an hour
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
Scant lochia rubra
The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?
Shallow chest breathing
Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate?
She should continue to breast-feed; mastitis won't infect the infant.
When assessing a male neonate, the nurse notices that the urinary meatus is located on the ventral surface of the penis. How should the nurse report this finding?
She should report the finding as hypospadias.
A primiparous client has just given birth to a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse interprets the father's actions as indicative of which of the following?
Singing to his son from the Koran in praise of Allah
Which of the following data collection findings would the nurse interpret as abnormal for a term male neonate who's 1 hour old?
Slight yellowish hue to the skin
A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the adverse effects include which of the following?
Slow pulse.
The nurse is assessing a 1-day-old neonate whose mother smoked 1 pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?
Small size for gestational age
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate?
Sometimes baby girls have this from hormones received from the mother."
A client is having contractions every 6-8 minutes apart lasting for 30 seconds and are mild in intensity. Her cervix is 2cm dialated, what stage and phase of labor is she in?
Stage One, Latent(Early) Phase
A laboring mom is 9 cm dilated and experiencing contractions every 2 minutes for 90 seconds each. Which stage and phase of labor is she in?
Stage One, Transition Phase
The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?
Staphylococcus aureus (S. aureus)
One minute after birth, a neonate has an Apgar score of 7. What should the nurse do?
Stimulate breathing by rubbing the neonate's back.
How does the nurse assess the rooting reflex of a neonate?
Stroking the neonate's cheek
To detect pulmonary embolus in a client in the immediate postpartum period, a nurse should be alert to which symptoms?
Sudden dyspnea and chest pain
A mother with a past history of varicose veins has just delivered her first baby. A nurse suspects that the mother has developed a pulmonary embolus. What would lead the nurse to this judgment?
Sudden dyspnea, diaphoresis, and confusion
A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom?
Sudden onset of shortness of breath
To promote comfort during labor, the nurse advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia?
Supine position
Which factor might result in a decreased supply of breast milk in a postpartum mother?
Supplemental feedings with formula
During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?
Support the neonate's head and back with the forearm.
Which of the following options is the most important aspect of nursing care in the postpartum period?
Supporting the mother's ability to successfully feed and care for her infant
Which factor is the most important in nursing care in the postpartum period?
Supporting the mother's ability to successfully feed and care for her neonate
The nurse is assessing the psychosocial status of a postpartum client. Which finding is most likely to promote parent-neonate attachment?
Sustained parent-neonate contact immediately after delivery
A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation?
Tachycardia
A client delivered a healthy full-term baby girl 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action?
Tachycardia and hypotension
In response to the nurse's question about how a postpartum client is feeling, the client replies that she is tired, sore, and hungry. She then begins to relate her birth experience. Based on these data, the nurse determines that the client is in which phase of postpartal psychological adaptation?
Taking in.
During a home visit on the fifth postpartum day, the client begins to cry and says that she is worried about her ability to care for her baby adequately. She tells the nurse, "I wish I could just get organized---I need 8 hours of sleep!" The nurse determines that she is experiencing which of the following?
Taking-hold phase of childbearing; she is feeling inadequate about neonatal care.
A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called?
Taking-in phase
On the first postpartum night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which phase?
Taking-in phase
A nurse observes several interactions between a mother and her neonate son. Which maternal behaviors should the nurse identify as evidence of mother-infant attachment?
Talks and coos to her son and cuddles her son close to her.
Which intervention should be helpful to a breast-feeding mother with engorged breasts?
Teaching how to express her breasts in a warm shower
For a breastfeeding client on the fourth postpartum day, which breast examination findings are normal?
Tender, intact nipples; firm, tender breasts; transitional milk
Which of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor?
Tetanic contractions
Which of the following correctly defines puerperium?
The 6 weeks following birth
Which assessment finding indicates that the infant isn't latching on properly during breast-feeding.
The baby's lips smack.
During the third postpartum day, which observation about a client should the nurse be most likely to make?
The client appears interested in learning more about neonatal care.
A nurse should expect to observe which behavior in a client on the 4th postpartum day?
The client asks many questions about the baby's care.
Which verbalization should be cause for concern to a nurse treating a postpartum client within a few days of delivery?
The client feels empty since she delivered the baby.
The nurse is reviewing the history of a postpartum client. Which history factor strongly suggests that this client will experience afterpains?
The client is a gravida 6, para 5.
A client, age 22, is a gravida 1, para 0. During the first 24 hours after delivery, she doesn't show consistent interest in her neonate. How should the nurse interpret her behavior?
The client is showing expected behaviors for the taking-in period.
Which client behavior indicates an understanding of the nurse's teaching plan for breastfeeding?
The client lets her nipples air-dry.
Which reason explains why a client might express disappointment after having a cesarean delivery instead of a vaginal delivery?
The client may feel a loss for not having experienced a "normal" birth
While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which of the following interpretations by the nurse is most appropriate?
The client needs application of an ice pack
Before giving a postpartum client the rubella vaccine, which fact should the nurse include in client teaching?
The client should avoid getting pregnant for 3 months after the vaccination because the vaccine has teratogenic effects.
Which activity by a client indicates that a nurse's teaching about perineal care has been effective?
The client uses a spray bottle to cleanse the perineum after urination and bowel movements.
A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?
The client will demonstrate self-care and infant care by the end of the shift
A clinical pathway is guiding care for an Rh-negative postpartum client who vaginally delivered a 9-lb, 1-oz (4,121-g) baby 5 hours ago. During the delivery, a second-degree median episiotomy was necessary. Which client outcome should be achieved during the first 12 hours postpartum?
The client will verbalize and demonstrate appropriate self-perineal care.
The nurse is discharging a 34-year-old multipara client who, after 16 hours of labor, delivered an 8-lb, 14-oz (4,032-g) baby vaginally. The nurse notes that the mother is rubella-immune with Rh-positive blood. Which client outcome takes priority for this client?
The client will verbalize the importance of reporting changes in lochia flow.
Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other childbirths were like this." The nurse's response to the client is based on the understanding of which of the following?
The client's feeling of grief is a normal reaction
A primiparous client who is breast-feeding develops endometritis on the third postpartum day. Which of the following instructions should the nurse give to the mother?
The condition typically is treated with I.V. antibiotic therapy.
An 11-month-old infant is diagnosed with an ear infection, his second one. The mother asks why children experience more ear infections than adults. The nurse shows the mother a diagram of the ear and explains the differences in anatomy. Identify the portion of the infant's ear that allows fluid to stagnate and act as a medium for bacteria.
The eustachian tube in an infant is shorter and wider than in an adult or an older child. It also slants horizontally. Because of these anatomical features, nasopharyngeal secretions can enter the middle ear more easily, stagnate, and tend to cause infections.
A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the neonate's father seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which interpretation of his behavior is most appropriate?
The father has depression because of grieving
When assessing the fetal heart rate tracing, the nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if which of the following occurs?
The fetal heart rate remains at greater than 160 beats/minute for 10 minutes.
A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation?
The increased lochia occurs from lochia pooling in the vaginal vault.
The nurse applies an external electronic fetal monitor (EFM) to assess a client's uterine contractions and evaluate the fetal heart rate (FHR). However, the client is uncomfortable and changes positions frequently, making FHR hard to assess. Consequently, the physician decides to switch to an internal EFM. Before internal monitoring can begin, which of the following actions must occur?
The membranes must rupture.
A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which of the following?
The mother can bring the daughter any foods that she desires
The nurse brings the infant to the new mother after obtaining assessment data and performing newborn interventions. Which of the following behaviors exhibited by the mother demonstrates that effective bonding is beginning to take place?
The mother looks at the newborn with direct eye contact
Which of the following explanations describes the rationale for administering vitamin K to every neonate?
The neonate lacks intestinal flora to make the vitamin.
Which finding requires further intervention in a mother who's breast-feeding?
The neonate's lips smack.
Which statement summarizes the underlying principle for the development of a parent-child relationship?
The relationship is based on the need for early and frequent parent-infant contact
A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first?
The time of membrane rupture
During the postpartum period, the nurse should assess for signs of normal involution. Which of the following would indicate that the client is progressing normally?
The uterus is descending at the rate of one fingerbreadth per day.
Which reason explains why Kegel exercises are advantageous to women after they deliver a child?
They promote blood flow, allowing for healing and strengthening the musculature
The nurse is collecting data on a neonate. Which finding indicates that the neonate's fontanels are normal?
They're soft to touch.
While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which of the following?
This is a normal adverse effect of phototherapy.
As part of the postpartum follow-up, the nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information, which of the following assessments would the nurse make?
This is expected behavior for a client 3 to 7 days postpartum.
Which of the following interventions would be appropriate to include in the plan of care for a client during the fourth stage of labor?
Time with the baby to initiate breast-feeding
A client recently gave birth to a boy. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug?
To stimulate lactation
The nurse is teaching a postpartum client how to perform Kegel exercises. What is the purpose of these exercises?
To strengthen the perineal muscles
A 32-year-old multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. What phase of labor is she in?
Transitional phase
The nurse is caring for a client who's in the first stage of labor. What is the shortest but most difficult part of this stage?
Transitional phase
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?
Transitional phase
A client is in the third stage of labor. Which finding indicates impending placental separation?
Umbilical cord lengthening
A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which data collection finding may indicate the need for cesarean delivery?
Umbilical cord prolapse
The nurse is collecting data on a baby boy born 3 hours ago. Which finding would make the nurse suspect a congenital hip dislocation?
Unequal gluteal folds
The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (89 ml) or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find in the neonate?
Upturned nose
Which finding would lead the nurse to suspect that a client has developed hypovolemic shock caused by postpartum hemorrhage?
Urine output less than 25 ml/hour
Which circumstance is most likely to cause uterine atony and lead to postpartum hemorrhage?
Urine retention
A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?
Use a warm moist compress over the painful area
A client who is breast-feeding her baby experiences pain, redness, and swelling of her left breast 9 days postpartum. She is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?
Use a warm, moist compress over the painful area.
A client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery?
Use the football hold to avoid incisional discomfort.
The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?
Using a peri bottle to clean the perineum after each voiding or bowel movement
During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a post-term neonate after oxytocin induction. When developing the client's plan of care, which of the following should the nurse expect to assess for frequently?
Uterine atony
Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?
Uterine atony
A pregnant client with a history of cardiac dysfunction has been taking propranolol (Inderal), a beta-adrenergic blocker, to treat hypertension. During labor, the nurse should stay alert for which adverse effect of this drug?
Uterine hypertonus
A 6-week-postpartum client is being assessed by the nurse at the obstetrician's office. The nurse notes that the uterus is enlarged and soft and that the client is experiencing vaginal bleeding. The nurse suspects the client has which condition?
Uterine subinvolution
Four hours after cesarean birth of a neonate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which of the following?
VBAC may be possible if the client has not had a classic uterine incision
Which finding is normal for a postpartum client who has experienced a vaginal birth?
Vaginal dryness after the lochial flow has ended
Breast engorgement occurs on the second or third postpartum day. Which of the following processes causes engorgement?
Vasodilation, which causes the breast to feel full
Meconium aspiration syndrome is suspected in a neonate. What's the most accurate diagnostic tool used to confirm the diagnosis?
Vocal cord examination using a laryngoscope
A client has received dinoprostone (Prostin E2) to help ripen her cervix. The nurse should monitor the client for which adverse effect?
Vomiting
The nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?
Washing the hands and wearing gloves
What is a common adverse effect of phototherapy?
Watery stools
Which finding is considered normal in the neonate during the first few days after birth?
Weight loss, then return to birth weight
Which of the following should be the nurse's initial action immediately following the birth of the neonate?
Which of the following should be the nurse's initial action immediately following the birth of the neonate?
A client who has been in the latent phase of the first stage of labor enters the transition to the active phase. During the transition, the nurse expects to see which client behavior?
Withdrawal, irritability, and resistance to touch
The nurse visits a client at home on the tenth postpartum day. When assessing the client's uterus, the nurse expects to find:
a nonpalpable fundus in the abdomen.
A client, age 19, has an episiotomy to widen her birth canal. Delivery extends the incision into the anal sphincter. This complication is called:
a third-degree laceration.
When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be:
about half as long as her first labor.
A client who had a cesarean birth 1 day ago asks for pain medication when the nurse enters the room to perform her shift assessment. The client states that her pain level is an 8 on a 0-to-10-point scale. The priority of care should be for the nurse to:
administer any ordered pain medication
The third stage of labor ends:
after the birth of the placenta.
The nurse assesses a client for evidence of postpartum hemorrhage during the third stage of labor. Early signs of this postpartum complication include:
an increased pulse rate, increased respiratory rate, and decreased blood pressure.
A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the:
area between the dura mater and the ligamentum flavum.
A primigravid client is admitted to the labor and delivery area. Assessment reveals that she's in the early part of the first stage of labor. Her pain is likely to be most intense:
around the pelvic girdle.
A client in transition complains to the nurse that the physician was verbally abusive and "rough during a vaginal exam." Just then, the physician reappears and asks the nurse for a sterile glove for another vaginal check. The nurse's first priority should be to:
ask the physician to step out of the room and then discuss with him the need to transfer care to another physician.
The physician decides to artificially rupture the membranes. Following this procedure, the nurse checks the fetal heart tones to:
assess for prolapsed cord.
An appropriate-for-gestational-age neonate should weigh:
between the 10th and the 99th percentiles for age.
On the first postpartum day after a cesarean birth, the client is ordered a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which of the following?
bowel sounds
A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to:
breast-feed every 1½ to 3 hours.
Normal lochial findings during the first 24 hours following delivery include:
bright red blood.
Normal lochial findings in the first 24 hours after birth include:
bright red blood.
A girl neonate is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the neonate under the radiant heater, the nurse's next action should be to:
check the neonate's blood glucose level.
A primigravid client gives birth to a full-term girl. When teaching the client and her husband how to change their neonate's diaper, the nurse should instruct them to:
clean and dry the neonate's perineal area from front to back.
The nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The nurse knows that the goal of phototherapy is to:
decrease the serum unconjugated bilirubin level.
A client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves:
determination of the fertile period to identify safe times for sexual intercourse.
The nurse is teaching a client about oral contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct her to:
discard the pack, use an alternative contraceptive method until her menses begins, and start a new pack on the regular schedule.
A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to:
discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule.
Which physiologic response should the nurse expect during the early postpartum period?
diuresis
A postpartum client plans to breast-feed her first child, a full-term neonate. She asks the nurse, "How will I know if my baby is getting enough to eat?" The nurse informs her that nutritional intake is adequate if the neonate:
exhibits a steady weight gain.
The nurse is recording an Apgar score for a neonate. The nurse should assess:
heart rate, respiratory effort, reflex irritability, and color.
A client who delivered her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." The nurse should:
help the client break down large tasks into smaller ones.
A client who gave birth to her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." The nurse should:
help the client break down large tasks into smaller ones.
In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?
hemorrhage
A client with human immunodeficiency virus (HIV) infection gives birth to an HIV-positive neonate. When assessing the neonate, the nurse is likely to detect:
hepatosplenomegaly.
A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to:
hold the neonate after the mother gives permission.
A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of:
how well the neonate tolerated labor.
A client with moderate pregnancy-induced hypertension (PIH) is a poor candidate for regional anesthesia during labor and delivery. If she were to receive this form of anesthesia, she might experience:
hypotension.
When assessing the neonate of a client who used heroin during her pregnancy, the nurse expects to find:
irritability and poor sucking.
Moments after birth, a neonate of 32 weeks' gestation develops asphyxia. As the neonatal team starts resuscitation, the nurse must:
keep the neonate's head in the "sniff" position.
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:
lethargy
One day after a client gives birth, the nurse performs a postpartum assessment. At this time, the nurse expects to find:
lochia rubra.
After 2 days of breast-feeding, a postpartum client reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:
lubricate her nipples with expressed milk before feedings.
Parents of a neonate born with severe congenital anomalies have requested that the staff institute a do-not-resituate (DNR) order. While working with this family, the nurse applies the ethical principle of autonomy by:
making sure the parents are well informed about their infant's condition and that they've made an informed decision.
During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a precipitous delivery by:
massaging and supporting the perineum.
The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks only Spanish and gave birth to a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client's intake of which of the following?
meat products
As part of the respiratory assessment, the nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because:
neonates are obligate nose breathers.
It's difficult to awaken a neonate 3 hours after birth. The nurse recognizes that this behavior indicates:
normal progression into the sleep cycle.
When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to:
prevent seizures.
The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward:
preventing infection.
Which oral contraceptive is considered safe for use while breast-feeding because it will not affect the breast milk or breast-feeding?
progestin
During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother
pushes only the tip of the nipple into the neonate's mouth
During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother:
pushes only the tip of the nipple into the neonate's mouth.
The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be:
red and moderate.
A client is experiencing true labor when her contraction pattern shows:
regular contractions that increase in frequency and duration.
A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar score, the nurse assesses the neonate's:
respiration.
The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity:
results from exposure of an antigen through immunization or disease contact.
After delivering an 8 lb (3.6 kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of:
sterile water.
During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his mouth. To resolve this problem, the nurse should suggest that the mother:
stroke the neonate's lips gently with the nipple.
A client says she wants to practice natural family planning. The nurse teaches her how to use the calendar method to determine when she's fertile and advises her to avoid unprotected intercourse. When teaching her how to determine her fertile period, the nurse should instruct her to:
subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle.
While talking to the nurse, the parents of a neonate in the neonatal intensive care unit (NICU) express concern that they're neglecting their 3-year-old son. The nurse suggests a sibling visit. To best promote the sibling's attachment to the neonate, the nurse should:
suggest that the sibling bring in a drawing to display near the neonate's crib in the NICU.
To minimize the amount of a drug received by an infant through breast-feeding, the nurse should tell the mother to:
take the medication immediately after breast-feeding.
Puerperium is defined as
the 6 weeks following birth.
A client is concerned that her 2-day-old, breast-feeding neonate isn't gaining weight. The nurse should teach the client that breast-feeding is effective if:
the neonate latches onto the areola and swallows audibly.
A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-feeding within 30 minutes of the neonate's birth because:
the neonate will be responsive and eager to suck at this time.
The nurse should tell new mothers who are breast-feeding that breast milk is produced when:
the placenta is delivered, causing the secretion of prolactin.
A client is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the client's risk of:
tubal or ectopic pregnancy.
When assessing an 18-year-old primipara who gave birth to a viable neonate under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assesses for:
urinary retention
When caring for a breast-feeding client who delivers by cesarean section, the nurse should teach the client to:
use the football hold position to avoid incisional discomfort
A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for:
uterine atony.
During the fourth stage of labor, the client should be assessed carefully for:
uterine atony.
A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she:
wear a supportive, well-fitting brassiere.
A full-term neonate is diagnosed with hydrocephalus. Data collection is likely to reveal:
wide or bulging fontanels.
What is pitocin drug half-life and where should it be administered and why?
• 6 min. 1/2 life • Closest port to IV site • To provide tight control of medication infusion
The nurse assigns an unlicensed assistive personnel to care for a client who is one day postpartum. Which of the following would be appropriate to delegate to this person? Select all that apply.
• Changing the perineal pad and reporting the drainage. • Reinforcing good hygiene while assisting the client with washing the perineum. • Assisting the client with ambulation shortly after delivery.
The nurse is caring for a client in the newborn nursery. Which of the following are appropriate actions for the nurse to take that will help to prevent neonatal infection? Select all that apply.
• Good hand washing technique • Isolation of infected infants with communicable disease • Hand sanitizer with points of contact
The nurse palpates a client's fundus, and notes it is 1 in. (3 cm) above the umbilicus and displaced to the right. Which of the following would be priority nursing actions? Select all that apply.
• Have the client void and reassess the fundus. • Ask the client how many pads she is soaking per hour.
A nurse is assisting a grieving client and his/her spouse to deal with their loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply.
• Provide an early opportunity for the couple to see their child if they desire. • Offer to stay with the grieving parents. • Answer the parents' questions accurately
The nurse assesses for complications in a newborn infant born with assistance of forceps. Which of the following findings would indicate a need for further assessment? Select all that apply.
• Reduction of movement in one of the infant's arms • Lifting causes the infant to cry • Loss of sensation in one the infant's arms
While instructing the client about breast-feeding, which instructions should the nurse include to help the mother prevent mastitis? Select all that apply.
• Wash your hands before handling your breast and breast-feeding. • Expose your nipples to air part of the day. • Change the breast pads frequently. • Release the baby's grasp on the nipple before removing him or her from the breast