Maternal Newborn

Weight gain during pregnancy

1.1-4.4 lb (0.5-2.0 kg) weight gain in the first trimester is normal and indicates a good, healthy diet and a growing fetus. After the first trimester, a weight gain of 1 lb (0.5 kg) per week is often expected. This weight gain varies by pre-pregnancy BMI.

Postpartum depression

4-6 weeks postpartum, last up to 12 months Symptoms Extreme sadness, irritability, emotional outbursts, severe mood swings; can present with postpartum anxiety Treatment Supportive care plus pharmacologic intervention &/or psychotherapy

Normal blood glucose

50-60 mg/dL

Moderate variability

6-25 bpm

Minimal variability

< or equal to 5 bpm Etiology: CNS depressants (narcotics, alcohol, illicit drugs) temporary fetal sleep prematurity fetal hypoxia

Marked variability

> 25 bpm

normal glucose screen values

A 1-hour glucose screen, performed between 24 and 28 weeks gestation to screen for gestational diabetes, is considered abnormal if the result is ≥140 mg/dL.

Non stress test results

A nonstress test (NST) evaluates fetal status by monitoring the fetal heart rate (FHR) with an external monitor. After 20 minutes, if there are ≥2 FHR accelerations of 15 beats above baseline lasting at least 15 seconds, the NST is considered reactive, indicating fetal well-being.

A therapeutic magnesium level

A therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic client.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations 2. Inversion of the uterus 3. Uterine atony 4. Vaginal hematoma

A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma. (Option 1) Cervical lacerations should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage. Severe pain or a feeling of fullness is not associated with cervical lacerations. (Option 2) Complete inversion of the uterus presents with a large, red mass protruding from the introitus. (Option 3) Uterine atony presents with a boggy uterus on palpation and an increase in vaginal bleeding. Educational objective: Vaginal hematomas are formed following trauma to the tissues of the perineum during vaginal delivery (eg, vacuum- or forceps-assisted delivery, episiotomy). The client reports severe pain or a persistent feeling of fullness in the region. Assessment shows a firm, midline uterine fundus with minimal or unchanged vaginal bleeding.

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention? 1. Client has not been taking prenatal vitamins 2. Client is taking lisinopril to control hypertension 3. Client reports a whitish vaginal discharge 4. Client reports mild cramping pain in the lower abdomen

Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril, lisinopril, ramipril) and angiotensin II receptor blockers (eg, losartan, valsartan, telmisartan) should be avoided in clients who are planning to become pregnant. These drugs are teratogenic, leading to fetal renal and cardiac abnormalities, and are contraindicated in all stages of pregnancy. Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are teratogenic and need to be discontinued when planning pregnancy.

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counterpressure to the client's sacrum during contractions 2. Encouraging the client to remain in bed during early labor 3. Positioning the client on the left side with pillows for support 4. Requesting that the nurse anesthetist administer epidural anesthesia

Applying counterpressure to the client's sacrum during contractions Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis). The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, heel of the hand, or other firm object (eg, tennis ball, back massager) (Option 1). (Option 2) Clients should be encouraged to change positions frequently (every 30-60 minutes) during labor to promote fetal rotation/descent and increase maternal comfort. Remaining in bed during early labor increases the risk for persistent fetal malposition and slows labor progression. (Option 3) Left lateral positioning is better for uteroplacental blood flow and fetal oxygenation than supine positioning when the client is resting in bed. However, it may not alleviate the client's back pain. (Option 4) Although epidural anesthesia can provide effective pain relief, it can limit client mobility and contribute to persistent fetal malposition. This client is also still in early labor and has not requested an epidural at this time. Educational objective: Fetal occiput posterior position may cause intense back pain during labor. Client comfort can be increased by applying counterpressure to the sacrum during contractions

Breastfeeding

Breastfeeding should be on demand and last approximately 15-20 minutes per breast for newborns. The infant should be held "tummy to tummy" at nipple level. The nipple and part of the areola should be grasped in the infant's mouth. Before removing the infant from the breast, the suction should be broken using a finger inserted beside the gums.

Hyperemesis gravidarum

Clinical features Weight loss Poor skin turgor Dry mucous membranes Hypotension Tachycardia Laboratory abnormalities Hypokalemia/hyponatremia Ketonuria Increased urine specific gravity Hemoconcentration Metabolic alkalosis

Transition phase

Contractions every 2-3 minutes and dilation from 8 to 10 cm.

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia 2. Fetal tachycardia with moderate variability 3. Increased anxiety and discomfort with contractions [8%] 4. Painful, strong contractions every 3-4 minutes

Cessation of contractions and maternal tachycardia Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option 1). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. (Option 2) Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. However, moderate variability is a reassuring sign predictive of adequate fetal oxygenation. (Option 3) Contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture. (Option 4) The nurse should be hypervigilant for tachysystole, which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern. Educational objective: Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

The nurse is reinforcing instructions to a parent about how to care for a newly circumcised newborn. Which statement by the parent indicates a need for further teaching? 1. "Discharge and odor indicate infection of the circumcision site." 2. "I will clean the area with alcohol-based wipes or soap water." 3. "Infant crying during petrolatum gauze changes is expected." 4. "The diaper should be changed at least every 4 hours."

Complications of circumcision include hemorrhage, infection, and voiding difficulty. The area should be cleaned with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged alcohol-based wipes delay healing, cause discomfort, and should be avoided until the circumcision scar is healed (usually 5-6 days). (Option 1) Immediately after the procedure, the glans penis should appear dark red and, after 24 hours, will be covered with a yellow exudate that will persist for 2-3 days. Parents should not try to wipe or forcefully remove the exudate as this is part of the normal healing process. However, redness, swelling, odor, and discharge indicate infection. (Option 3) Crying is expected during diaper and petroleum (Vaseline) gauze changes. Parents are often anxious and concerned about inflicting pain on their newborn. They should be informed that the discomfort is only brief and be encouraged to provide extra comfort measures (holding, feeding, nonnutritive suckling) after diaper changes. (Option 4) Diapers should be changed when soiled or at least every 4 hours to keep the area clean and assess for evidence of infection or bleeding. Petroleum gauze or ointment should be applied at every diaper change (unless Plastibell is used) to prevent sticking. The diaper should be secured loosely to minimize pressure against the circumcision site. Educational objective: In a recently circumcised newborn, parents should be taught to use only warm water for cleaning and avoid soap and alcohol-based wipes. After 24 hours, a yellow exudate forms as part of the normal healing process; it should not be removed. Pain is expected, and parents can provide additional comfort measures after diaper changes to minimize discomfort.

Normal uterine contractions Duration

last 45-80 seconds, should not exceed 90 seconds

Cephalohematoma

subperiosteal bleed that does NOT cross the line

Warning signs of a PE include sudden anxiety and shortness of breath.

sudden anxiety and shortness of breath.

Leukorrhea

thin, milky white vaginal discharge that is normal during pregnancy. It is caused by increased levels of estrogen and is harmless. However, leukorrhea may become a problem if it changes color or develops a discernible odor, or if itching or burning occurs.

Ectopic pregnancy symptoms

unilateral abdominal pain hypotension (dizziness, tacky) referred shoulder pain

The practical nurse is collecting data on several clients waiting to be seen in the prenatal clinic. Which client situation is most important to report to the registered nurse? 1. 18 weeks gestation client taking ceftriaxone and reporting mild diarrhea 2. 22 weeks gestation client with twins who is taking acetaminophen twice a day 3. 28 weeks gestation client taking metronidazole who has dark-colored urine 4. 32 weeks gestation client taking ibuprofen for moderate back pain

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, indomethacin, or naproxen, inhibit prostaglandin synthesis and can be taken to decrease pain and inflammation or reduce a fever. Ibuprofen is assigned the pregnancy category C through 29 weeks gestation and pregnancy category D starting at 30 weeks gestation. It must be avoided starting at 30 weeks gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus and prolonged labor in the client. Prior to 30 weeks gestation, ibuprofen should be taken only if the benefits outweigh the risks and under the supervision of a health care provider.

Normal RR for newborns

Normal newborn respiratory rate is 30-60 breaths per minute

Latent phase

Onset of uterine contractions and ends with rapid cervical dilation of 1-5 centimeters. Contractions occur every 5-8 centimeters, and every 15-30 seconds with mild intensity.

Optimal glucose levels

Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal

The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk has a pink color. What is the nurse's initial action? 1. Apply oxygen and count respirations 2. Assess heart sounds for a murmur 3. Observe for expiratory grunting 4. Place infant skin-to-skin with mother

Place infant skin-to-skin with mother Acrocyanosis manifests as bluish coloration of the hands and feet in the newborn and is considered a normal finding during the first day of life or if the newborn becomes cold. Initial nursing management is to keep the infant warm by placing skin-to-skin with the mother or under a radiant warmer.

WBC during pregnancy

During pregnancy, the white blood cell (WBC) level increases to support the immune system; WBC levels can reach 16,000/mm3 during pregnancy (non-pregnancy normal: 4,000-11,000/mm3).

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply. 1. Blood pressure 82/64 mm Hg 4. Pulse 120/min 5. Shoulder pain

Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity. The majority of ectopic pregnancies occur in the fallopian tubes. Risk factors include recurrent sexually transmitted infections, tubal damage or scarring, intrauterine devices, and previous tubal surgeries (eg, tubal ligation for sterilization). Clinical manifestations are lower-quadrant abdominal pain on one side, mild to moderate vaginal bleeding, and missed or delayed menses. Signs of subsequent hypovolemic (hemorrhagic) shock from ruptured ectopic pregnancy include dizziness, hypotension, and tachycardia. Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. Peritoneal signs (eg, tenderness, rigidity, low-grade fever) may develop subsequently. (Options 2 and 3) Distended jugular veins and lung crackles indicate volume overload. The main risk with ectopic pregnancy is hypovolemic (hemorrhagic) shock. Jugular veins would be flat in hypovolemic shock. Educational objective: The fallopian tubes are the most common site for an ectopic pregnancy. As the ectopic pregnancy grows and expands, rupture may occur, resulting in active bleeding that progresses to life-threatening hypovolemic (hemorrhagic) shock. Signs of ruptured ectopic pregnancy may include severe abdominal pain, dizziness, and referred shoulder pain.

Caput succedaneum

Edema/hematoma above periosteum that crosses suture lines

Epstein's pearls

Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks.

The registered nurse is preparing to administer oxytocin to induce labor in a client. The practical nurse assists the registered nurse and recognizes that the oxytocin infusion can lead to which of the following conditions? 1. Decreased postpartum hemorrhage [18%] 2. Delayed milk production [5%] 3. Fetal distress and cesarean birth [65%] 4. High risk of placenta previa [10%]

Fetal distress and cesarean birth Oxytocin (a uterine stimulant) is used to induce labor. Contractions can become too strong after oxytocin is administered and lead to reduced placental blood flow. This can result in non-reassuring fetal heart rate (FHR) patterns (eg, late decelerations, fetal bradycardia, tachycardia, minimal variability). These non-reassuring FHR patterns may necessitate emergency cesarean birth, which would not have been required had labor not been induced. (Option 1) After birth, the nurse should observe for postpartum hemorrhage, especially if the client received oxytocin for a long period. The uterine muscles become fatigued and may not contract effectively to compress vessels at the placental site. (Option 2) Oxytocin, a hormone secreted by the pituitary, triggers the milk ejection/let-down reflex (release of milk from the alveoli into the ducts). Prolactin is the pituitary hormone regulating milk production. Exogenous oxytocin has no known effects on milk production. (Option 4) Greater uterine activity from oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa is abnormal implantation and is unrelated to oxytocin infusion. Educational objective: Oxytocin, a uterine stimulant, is frequently used to induce labor. Oxytocin infusion can result in quick delivery, but it increases the risk for unnecessary cesarean birth (due to fetal heart rate abnormalities), postpartum hemorrhage, and placental abruption.

Active phase

First stage of labor when cervix is dilated from 5-8 centimeters.

GTPAL

G: gravida - number of times a woman has been pregnant T: term - the number of pregnancies delivered at 37 week 0 days gestation and beyond P: preterm - the number of pregnancies delivered from 20 week 0 days gestation through 36 weeks and 6 days gestation A: abortion - the number of pregnancies ending before 20 week 0 day gestation; spontaneous or induced L: living - number of currently living children

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage? 1. Infant birth weight of 9 lb 2 oz (4139 g) 2. Labor and birth without pain medication 3. Labor that lasted 8 hours 4. Third stage of labor lasting 20 minutes

Infant birth weight of 9 lb 2 oz (4139 g)

Jaundice

Jaundice is best assessed in natural lighting, with gentle pressure to the skin over a firm surface such as the nose, forehead, or sternum. It first appears on the face and extends to the trunk and eventually the entire body. Jaundice within the first 24 hours is pathological. It is usually related to problems of the liver. Jaundice after 24 hours is referred to as physiological jaundice and is related to the increased amount of unconjugated bilirubin in the system.

Leopold maneuvers

Leopold maneuvers are used as a systematic approach to palpating the pregnant abdomen to identify fetal presentation. These are not used as emergency interventions for umbilical cord prolapse.

The initial prenatal laboratory screening results of a client at 12 weeks gestation indicate a rubella titer status of nonimmune. What will the nurse anticipate as the plan of care for this client? 1. Administer measles-mumps-rubella (MMR) vaccine now 2. Administer MMR vaccine immediately postpartum 3. Administer MMR vaccine in the third trimester 4. An MMR vaccine is not indicated for this client

In a pregnant client, a serum sample is collected at the first prenatal visit to determine immunity to the rubella virus. A positive immune response indicates immunity to the rubella virus, attributed to either past infection or vaccination. A negative, or nonimmune, response indicates that the client is susceptible to rubella disease and requires vaccination. An equivocal response indicates partial immunity to rubella and is treated clinically the same as nonimmune status. Measles-mumps-rubella (MMR) is a live attenuated vaccine. Live vaccines are contraindicated in pregnancy due to the theoretical risk of contracting the disease from the vaccine. Maternal rubella infection can be teratogenic for the fetus. The fetal effects of congenital rubella syndrome include congenital cataracts, deafness, heart defects (patent ductus arteriosus), and cerebral palsy. The best time to administer an MMR vaccine to a nonimmune client is in the postpartum period just prior to discharge (Option 2). The MMR vaccine can safely be administered to breastfeeding clients. (Options 1 and 3) MMR vaccine is contraindicated in pregnancy. Also, pregnancy should be avoided for at least 1-3 months after the immunization is given. (Option 4) This client is rubella nonimmune and is susceptible to rubella if exposed. The vaccine should be offered in the postpartum period. Educational objective: The measles-mumps-rubella vaccine is a live attenuated vaccine and is contraindicated in pregnancy due to the risk of teratogenic effects to the fetus. Clients who are nonimmune to rubella should receive the vaccine in the postpartum period. Pregnancy should be avoided for at least 1-3 months after immunization.

During the first prenatal assessment, the client reports the last normal menstrual period starting on March 1 and ending on March 5, but also slight spotting on March 23. The client had unprotected intercourse on March 15. Using Naegele's rule, what is the estimated date of birth? 1. December 8 2. December 12 3. December 22 4. December 30

Naegele's rule can be used to quickly determine an EDB early in the pregnancy. This calculation uses the date of the first day of the last normal menstrual period (LMP) for determination of EDB. EDB = (LMP minus 3 months) + 7 days This client's LMP is March 1, minus 3 months = December 1. Add 7 days to obtain EDB = December 8.

Manifestations of NAS

Neuro: Irritability, hypertonia, jittery movements, seizures GI: diarrhea, vomiting, feeding intolerance Autonomic: sweating, sneezing, pupillary dilation

Fundal Height measurement

The client's fundal height is measured, in centimeters, during pregnancy to assess fetal and uterine growth. This should be done at each prenatal visit. The fundus can be palpated above the symphysis pubis at 12-14 weeks gestation and correlates approximately with gestational age until 36 weeks gestation. The fundal height should be at the level of the client's umbilicus at 20-22 weeks gestation. (Option 1) The fundus should be at this level at 36 weeks gestation. (Option 2) The fundus should be at this level at 28 weeks gestation. (Option 4) The fundus should be at this level at 12 weeks gestation. Educational objective: The fundus should be palpated and the height measured at each prenatal visit. The fundus should be at the level of the client's umbilicus at 20-22 weeks gestation.

Proper Car Seat instructions

Proper car seat use instructions include the following: Infants should be placed in a federally-approved, rear-facing safety seat that is secured in the back seat of the car (Option 3). The harness should be snug, with the retaining clip secured near the level of the armpits. If the newborn is preterm or small, rolled blankets or car seat inserts (on both sides and under the crotch level buckles) may be used to support the trunk and reduce slouching (Option 1). Infants should be positioned at a 45-degree angle to prevent airway obstruction.

A full-term newborn of a mother with gestational diabetes is slightly jittery with a blood glucose level of 45 mg/dL. The practical nurse (PN) is assisting the registered nurse to implement the appropriate intervention. Which action does the PN anticipate first? 1. Administer oral glucose 2. Feed the newborn 3. Notify the pediatrician 4. Warm the room

Poorly controlled diabetes mellitus during pregnancy subjects the fetus to high blood glucose levels. Fetal hyperglycemia leads to insulin hypersecretion by the fetus, which promotes abnormal growth and storage of excess calories as fat (macrosomia). After birth, the infant is no longer exposed to the mother's high blood glucose levels, but a transient hyperinsulinemic state will persist for several days, during which the infant is susceptible to developing hypoglycemia. The normal range for serum glucose in a newborn at day 1 is 50-60 mg/dL; however, no standard definition for newborn hypoglycemia currently exists. Treatment plans are based on clinical signs and overall status of the infant. The most common sign of low blood glucose is jitteriness or tremors. If the blood glucose is low, newborns should be fed immediately with formula or breast milk (Option 2). If the infant continues to exhibit signs of hypoglycemia and/or blood glucose levels are <40-45 mg/dL after feeding, the pediatrician should be notified (Option 3). Further treatment, such as oral or IV glucose, may be required. (Option 1) A hypertrophied pancreas is very sensitive to blood glucose levels. Oral glucose administration would cause massive release of insulin and produce rebound hypoglycemia. Feeding the newborn with breast milk or formula would be sufficient in most situations. (Option 4) Although cold stress may exacerbate existing hypoglycemia, warming the room is not the best initial intervention. Feeding this infant is the priority as there are early clinical signs of hypoglycemia. Educational objective: Hypoglycemia can occur in infants born to mothers with gestational diabetes due to elevated insulin levels and consumption of stored glucose. The most common sign of hypoglycemia is jitteriness or tremors. The newborn should be fed breast milk or formula immediately.

A client at 38 weeks gestation is in labor and receiving an oxytocin infusion. The continuous fetal heart rate (FHR) monitor displays the strip shown in the exhibit. Which action by the nurse is most appropriate? Click on the exhibit button for additional information. 1. Discontinue oxytocin infusion 2. Place client in the side-lying position 3. Provide oxygen 10 L/min via face mask 4. Review medication administration record

Review medication administration record The baseline FHR is normal (110-160/min), and occasional accelerations and early decelerations are reassuring findings. In the presence of these findings, minimal variability may indicate temporary fetal sleep (usually <30 minutes) or central nervous system (CNS) depression. The nurse should first check the medication administration record for recently administered CNS depressants (eg, opioid analgesics). However, minimal or absent variability requires further assessment if accompanied by late decelerations, as it may indicate fetal hypoxemia or acidosis. Late decelerations indicate utero-placental insufficiency and require nursing interventions to prevent complications. The nurse should place the client in a side-lying position to relieve pressure on the vena cava and place oxygen via face mask to increase placental perfusion. Late decelerations indicate that the fetus is not tolerating the contractions and oxytocin (Pitocin), a medication that stimulates contractions, should be stopped.

HELLP syndrome S&S

Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present.

Risk factors for PPH

Risk factors for PPH include: History of PPH in prior pregnancy Uterine distension due to: - Multiple gestation - Polyhydramnios (ie, excessive amniotic fluid) - Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option 1) - Uterine fatigue (labor lasting >24 hours) - High parity Use of certain medications: - Magnesium sulfate - Prolonged use of oxytocin during labor - Inhaled anesthesia (ie, general anesthesia)

The nurse is reinforcing teaching about infant safety to a class of expectant parents. Which statement by a participant indicates a need for further instruction? 1. "I will make sure there is a firm mattress in the crib." 2. "I will put my baby to bed with a pacifier." 3. "I will tie bumper pads to the sides of the crib to protect my baby's head." 4. "I will use a sleeping sack or a thin blanket that I tuck to cover my baby."

Sudden infant death syndrome (SIDS) is the leading cause of death among infants age 1 month to 1 year. Nurses play a crucial role in teaching parents about child care practices that reduce the risk of SIDS, which include the following: Place infants age <1 year for sleep on their backs on a firm surface. The prone or side-lying position should never be used. Infants should not share a bed with parents/caregivers. Avoid soft objects such as stuffed animals, heavy blankets, and pillows in the infant's bed. A thin blanket tucked into the sides and bottom of the mattress can be used to cover the infant. Avoid bumper crib pads, which have not been shown to be effective in preventing infant injury and likely increase the risk of SIDS (Option 3). Maintain a smoke-free environment. Avoid overheating; if the infant is wearing a sleeper ("onesie") or a sleeping sack, even a tucked blanket may not be necessary. A fan may help reduce the temperature and circulate air in a warm room. Use a pacifier (age >1 month to ensure that breastfeeding has been established for those who are being breastfed) when placing the infant for sleep. Breastfeed and keep the infant's immunizations up to date.

The McRoberts maneuver

The McRoberts maneuver consists of sharply flexing the thigh onto the maternal abdomen to straighten the sacrum. It is used for shoulder dystocia and will not take pressure off a prolapsed umbilical cord.

most common sign of low blood glucose

The most common sign of low blood glucose is jitteriness or tremors.

Phototherapy

The newborn should be fully exposed, except for a diaper, when placed under phototherapy lights. Lotions and ointments should not be applied as they can absorb heat and cause burns. Newborns should wear eye shields and be monitored for adequate hydration and urine output.

Normal heart rate

The normal heart rate for a newborn is 110-160/min.

The nurse is assisting with a vaginal delivery of a full-term infant. Which assessment finding of the newborn is most important for the nurse to follow-up? 1. Flat bluish discolored area on the buttocks 2. Localized soft tissue edema of the scalp 3. Small amount whitish substance in axilla 4. Tuft of hair at the base of the spine

The neural tube develops into the brain and spinal cord. Spina bifida is a defect in which the spinal cord contents can protrude through the vertebrae that did not close. The mildest form is spina bifida occulta, most often at the fifth lumbar or first sacral vertebrae. A tuft of hair or a hemangioma may be seen over the site. This is distinguished from lanugo, which is fine downy hair on the back that gradually falls out; a term infant will have minimal lanugo. There has been less incidence of spina bifida as there is awareness of the role of folic acid during pregnancy. The defect needs surgical repair. Depending on the location of the defect, the child can have bowel and bladder incontinence, hydrocephalus, and sensory loss. (Option 1) Congenital dermal melanocytosis (Mongolian spots) are flat, bluish discolored areas on the lower back and/or buttock. It is most common in African American, Asian, Hispanic, and Native American infants. Although the nurse would document the size and location, it is benign and usually resolves on its own by school age. (Option 2) Caput succedaneum is a localized soft tissue edema of the scalp from the prolonged pressure of the head against the mother's cervix during labor. It feels "spongy" and crosses the suture line (caput succedaneum = crosses suture); cephalhematoma does not cross the suture lines. Caput succedaneum resolves within the first week of life. (Option 3) Vernix caseosa is a protective substance secreted by the sebaceous glands that covers the fetus during pregnancy. Described as white and cheesy, it is most likely to be seen in the axillary or genital area. Full-term infants typically have very little present. Educational objective: A tuft of hair at the base of the spine can be indicative of spina bifida occulta. Caput succedaneum, congenital dermal melanocytosis, and vernix caseosa are expected findings in a newborn.

A client in the postpartum unit has a temperature of 100.9 F (38.3 C) and tachycardia on the second day following a cesarean delivery. Examination shows uterine tenderness, fundus +2 above the umbilicus, moderate lochia rubra with a foul smell, and chills. Which prescription should the nurse implement first? 1. Acetaminophen 500 mg, 2 tablets orally for fever 2. Clindamycin and gentamicin, first dose 3. Insertion of saline IV lock 4. Serum laboratory draws for blood culture and sensitivity

This client's findings indicate a possible uterine infection (postpartum endometritis). Clients develop fever, chills, tachycardia, uterine tenderness, and foul-smelling lochia. Postpartum endometritis is usually caused by polymicrobial infection and is treated with broad-spectrum antibiotics. If the health care provider prescribes blood cultures (Option 4), they must be obtained prior to initiating antibiotic therapy as the medication may alter laboratory results (Option 2). After the results of the blood culture are obtained, the antibiotic prescribed may be changed for appropriate treatment. (Option 1) Acetaminophen administration for fever is not the priority action for this client. The nurse can treat the client's fever after blood cultures are drawn and IV antibiotic therapy is initiated. (Option 3) Placement of a saline IV lock for administration of antibiotics may be completed after obtaining a blood culture. Drawing a blood culture from an IV site is not recommended. Careful preparation of the skin prior to needle puncture will decrease the chance of specimen contamination. Educational objective: Postpartum uterine infection may occur following vaginal or cesarean delivery. A blood culture is obtained prior to starting broad-spectrum antibiotics.

Postpartum uterine atony Risk factors

Uterine fatigue from prolonged, induced, or precipitous labor Chorioamnionitis Uterine over-distension (multiple gestation, polyhydramnios) Retained placenta

Postpartum uterine atony interventions

Uterine fundal massage Correction of bladder distension Uterotonic medications (eg, oxytocin, methylergonovine, carboprost, misoprostol) IV fluids, blood, oxygen (if hemorrhage occurs) Possible surgical intervention (if unresolved)

Normal uterine contractions resting ton

average 10 mmhg, should not exceed 20 mmhg

Circumcision care at home includes:

- Wash hands before providing care - Avoid using alcohol-based prepackaged wipes as alcohol prevents healing and causes discomfort. Instead, clean with warm water (without soap) every 4 hours to remove urine and feces. - Apply petroleum jelly at diaper changes (unless PlastiBell used); the diaper should be loose over the penis. The diaper should be changed at least every 4 hours to prevent adhesion to the penis. - Yellow exudate forms as part of the normal healing process after the first 24 hours. It is not a sign of infection and should not be removed forcefully. The exudate will disappear in 2-3 days as healing progresses. Redness, odor, or discharge indicates infection.

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? 1. Hemoglobin and hematocrit levels 2. Human chorionic gonadotropin level 3. Serum folate level 4. White blood cell count

1. Hemoglobin and hematocrit levels Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? Select all that apply. 1. Influenza injection 2. Influenza nasal spray 3. Measles, mumps, and rubella 4. Tetanus, diphtheria, and pertussis 5. Varicella

1. Influenza injection 4. Tetanus, diphtheria, and pertussis

A client comes to the clinic indicating that a home pregnancy test was positive. The client's last menstrual period was September 7. Today is December 7. Which are true statements for this client? Select all that apply. 1. According to Naegele's rule, the expected date of delivery is June 14 2. Detection of the fetal heart rate via Doppler is possible 3. Fundal height should be 24 cm above the symphysis pubis 4. The client should be feeling fetal movement 5. Urinary frequency is a common symptom

1. According to Naegele's rule, the expected date of delivery is June 14 2. Detection of the fetal heart rate via Doppler is possible 5. Urinary frequency is a common symptom Naegele's rule, which is the last menstrual period minus 3 months plus 7 days, can be used to calculate a client's expected date of delivery. The accuracy of this method may be influenced by the regularity and length of the client's menstrual cycle. September 7 minus 3 months is June 7, plus 7 days is June 14 (Option 1). Detection of a fetal heart rate is possible using a Doppler by 10-12 weeks gestation (Option 2). Urinary frequency, a presumptive sign of pregnancy common in the first trimester, occurs primarily due to hormonal changes and anatomical changes in the renal system (Option 5). However, clients also reporting dysuria, fever/chills, or back pain should be evaluated for a urinary tract infection. (Option 3) Uterine growth is assessed by measuring fundal height using a measuring tape. After 20 weeks gestation, the fundal height measurement in centimeters should correlate closely with the number of weeks pregnant (eg, 24 cm = 24 weeks). The client should empty the bladder before having fundal height measured, as a full bladder can displace the uterus and affect measurement accuracy. (Option 4) Quickening, the awareness of fetal movements, occurs around 18-20 weeks gestation in primigravidas and at 14-16 weeks in multigravidas. Educational objective: Naegele's rule for estimating date of delivery is the last menstrual period minus 3 months plus 7 days. Fetal heart rate is detectable by Doppler at 10-12 weeks gestation. Urinary frequency is a presumptive sign of pregnancy in the first trimester.

A practical nurse is evaluating the external fetal monitoring strip of a laboring primigravida who is at 36 weeks gestation. Which nursing interventions should the practical nurse anticipate? Late decelerations 1. Administer supplemental oxygen by mask 2. Increase the IV fluid rate 3. Prepare the client for an amnioinfusion 4. Reposition the client to the supine position 5. Stop the client's oxytocin infusion

1. Administer supplemental oxygen by mask 2. Increase the IV fluid rate 5. Stop the client's oxytocin infusion (Option 3) An amnioinfusion is a transvaginal infusion of an isotonic fluid to compensate for the loss of amniotic fluid (oligohydramnios). (Option 4) The client should be placed on her right or left side to remove the pressure on the inferior vena cava by the gravid uterus and to provide adequate placental perfusion. Supine positioning can obstruct blood flow to the placenta. Late decelerations occur after the onset of a uterine contraction and continue beyond its end. They are caused by uteroplacental insufficiency. The lowest point of a late deceleration occurs near the end of the uterine contraction and may occur with marked hypertonia or increased uterine tone caused by oxytocin. The registered nurse should be notified about late decelerations, and immediate action must be taken. The client should be given oxygen by facemask and repositioned to the right or left side. Oxytocin should be stopped if it is being administered, and the IV fluid rate should be increased. If the deceleration pattern persists or variability becomes abnormal, the nurse should anticipate an imminent delivery.

The nurse is caring for a full-term newborn following vaginal delivery. Which nursing interventions should be implemented? Select all that apply. 1. Always wear gloves when handling the newborn before bathing 2. Cover the newborn to maintain a body temperature of 97.5-99 F (36.4-37.2 C) 3. During the initial bath, remove as much vernix caseosa as possible 4. Give a single dose of vitamin K intramuscularly 5. Suction the pharynx first, then the nasal passages

1. Always wear gloves when handling the newborn before bathing 2. Cover the newborn to maintain a body temperature of 97.5-99 F (36.4-37.2 C) 4. Give a single dose of vitamin K intramuscularly 5. Suction the pharynx first, then the nasal passages Nursing interventions for a newborn immediately after delivery include: Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg, gloves) are implemented when contact with blood or bodily fluid is anticipated. Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps with nasal suctioning. Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie consumption. Hypothermia predisposes the newborn to metabolic acidosis, hypoxia, and shock. A radiant warmer is used while performing assessments and interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin-to-skin contact aids in thermoregulation. Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent bleeding due to absence of vitamin K-producing intestinal bacteria. Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be delayed up to 1 hour after delivery. Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white coating, protects the skin and should not be vigorously removed (Option 3).

A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of wine on weekends. BMI is 32 kg/m2. Which teachings should the nurse reinforce as part of proper preconception health care for this client? Select all that apply. 1. Avoid eating undercooked hamburgers 2. Do not have more than 1 alcoholic drink per week 3. Maintain current BMI 4. Receive a rubella vaccine at least 3 months before attempting pregnancy 5. Take 0.4 mg folic acid supplementation daily

1. Avoid eating undercooked hamburgers 4. Receive a rubella vaccine at least 3 months before attempting pregnancy 5. Take 0.4 mg folic acid supplementation daily Preconception health care includes assessing for risk factors and implementing interventions (as appropriate) that will have a positive impact on a woman's health and future pregnancies. Interventions include the following: Folic acid supplementation to reduce the incidence of neural tube defects: The beneficial impact of folic acid supplementation is greatest between 1 month before pregnancy and the end of the first trimester, the period of neural tube development (Option 5). Abstaining from alcohol and illicit drugs Smoking cessation to prevent miscarriage and fetal growth retardation Maintaining up-to-date vaccinations: Significant birth defects can occur if an unvaccinated mother is exposed to the rubella virus during pregnancy. To prevent these complications, the rubella vaccine should be given at least 3 months before attempting a pregnancy (Option 4). Avoiding contact with raw/undercooked meats, cat feces, and unpasteurized foods: Toxoplasma is a protozoan parasite found in cat feces and uncooked or rare beef and lamb. Toxoplasmosis can cause intellectual disability, blindness, or fetal demise when the embryo is exposed (Option 1). (Option 2) Consumption of any alcohol in pregnancy is not known to be safe; complete abstinence is recommended. (Option 3) Achieving a normal BMI (18.5-24.9 kg/m2) will reduce risk for fetal and maternal complications. Being underweight before pregnancy increases the risk for poor fetal growth and low birth weight. Obesity (BMI >30 kg/m2) is associated with subfertility, gestational diabetes, hypertension, and large-for-gestational-age birth weight. Educational objective: Preconception care involves folic acid supplementation; maintaining a normal weight (BMI 18.5-24.9); receiving any missed vaccinations; abstaining from tobacco, alcohol, and illicit drugs; and avoiding contact with raw or undercooked meats.

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? 1. Bishop score of 10 2. Firm and posterior cervix 3. History of precipitous labor 4. Reactive nonstress test

1. Bishop score of 10 The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥8 usually indicates that induction will be successful (Option 1). (Option 2) A cervix that is firm and posterior is associated with a low Bishop score, which reflects a low likelihood of successful labor induction. (Option 3) A history of precipitous labor (<3 hours from onset of contractions to birth) may indicate that the client will again experience precipitous labor once labor is established. However, such a history is not an independent predictor of successful induction. (Option 4) A reactive nonstress test indicates that the fetus is well oxygenated and establishes fetal well-being. It does not provide information about the likely success or failure of labor induction. Educational objective: The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. A score >8 in nulliparous women is associated with successful induction and subsequent vaginal birth.

A practical nurse (PN) is assisting the registered nurse in caring for a client on oxytocin to induce labor. Which assessments does the PN anticipate during the infusion? Select all that apply. 1. Blood pressure 2. Fetal heart rate tracings 3. Intake and output 4. Knee reflexes 5. Uterine contraction pattern 6. Vaginal examination

1. Blood pressure 2. Fetal heart rate tracings 5. Uterine contraction pattern 6. Vaginal examination Fetal heart rate (FHR) pattern - Before induction, the registered nurse determines whether the FHR and patterns are reassuring. The FHR is charted in the labor record at least every 15 minutes during the first stage of labor and every 5 minutes during the second stage (Option 2). Contraction pattern - The nurse also monitors for contraction patterns that may lead to decreased placental perfusion. More than 5 contractions in 10 minutes or a series of single contractions lasting more than 2 minutes (tachysystole) may lead to reduced placental exchange and nonreassuring FHR patterns (Option 5). Vital signs - The client's blood pressure, pulse, and respirations are taken every 30 minutes or with each oxytocin dose change to identify changes from baseline (Option 1). Oxytocin infusion can cause hypotension. Intake and output - Oxytocin infusion has an antidiuretic effect and can cause water intoxication, resulting in dilutional hyponatremia and seizure risk. Urine output should be at least 120 mL every 4 hours. Recording intake and output identifies fluid retention, which precedes water intoxication (Option 3). Cervical dilation - The rate of oxytocin infusion may be gradually reduced when the client is in the active phase of labor, about 5-6 cm of cervical dilation. Oxytocin may be stopped or reduced after the client's membranes rupture (Option 6). (Option 4) Regular assessment of deep tendon reflexes (DTRs) (eg, knee reflexes) is necessary for clients receiving a magnesium sulfate infusion, which can cause central nervous system depression and result in loss of DTRs. Oxytocin is a uterine stimulant and does not have this effect. Educational objective: Excessive oxytocin infusion can cause water intoxication in the mother, hypotension, tachysystole, and reduced placental blood flow. The nurse must frequently assess changes in fetal heart rate, uterine contractions, vital signs, cervical dilation, and intake and output differences.

The nurse is reinforcing information about the prevention of sudden infant death syndrome to a client with a newborn. Which recommendations should the nurse include? Select all that apply. 1. Breastfeeding 2. Co-sleeping in parents' bed 3. Pacifier use at bedtime 4. Side-lying sleeping position 5. Smoking cessation by parents

1. Breastfeeding 3. Pacifier use at bedtime 5. Smoking cessation by parents

The nurse is reinforcing teaching to the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply. 1. Burp infant during and after feeds 2. Engage infant in active play after feeds 3. Feed infant in side-lying position 4. Lay infant in a car seat after each feeding 5. Offer infant smaller but more frequent feeds 6. Place infant on tummy after feeding

1. Burp infant during and after feeds 5. Offer infant smaller but more frequent feeds 6. Place infant on tummy after feeding

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply. 1. Capillary glucose of 60 mg/dL (3.3 mmol/L) 2. Holosystolic murmur auscultated at fourth intercostal space 3. Respirations of 56 breaths per minute 4. Single transverse crease across palm of the hand 5. White papules on bridge of the nose

1. Capillary glucose of 60 mg/dL (3.3 mmol/L) 3. Respirations of 56 breaths per minute 5. White papules on bridge of the nose During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal (Option 1). A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels. Normal newborn respiratory rate is 30-60 breaths per minute (Option 3). Breathing may be slightly irregular, diaphragmatic, and shallow. Milia (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks (Option 5). (Option 2) A holosystolic murmur (heard during entire systole phase) at the left lower sternal border is a classic sign of a ventricular septal defect (VSD). Although abnormal, most small VSDs close spontaneously within the first 6 months of life. (Option 4) A single transverse crease extending across the palm of the hand is a classic sign of Down syndrome (an extra copy of chromosome 21). Other signs include small and low-set ears, flat nose bridge, protruding tongue, and hypotonia. Educational objective: Expected findings for a neonate at 1-3 hours postpartum include respirations between 30-60 breaths per minute, milia, and glucose levels <70-100 mg/dL (3.9-5.6 mmol/L) but ≥40 mg/dL (2.2 mmol/L).

When assessing neonates in the nursery, the practical nurse should report which findings to the registered nurse? Select all that apply. 1. Chest wall retractions 2. Flaking skin on the feet 3. Head circumference of 30 cm 4. Jaundice of the head and sclera 5. No voiding in 24 hours

1. Chest wall retractions 3. Head circumference of 30 cm 4. Jaundice of the head and sclera 5. No voiding in 24 hours The practical nurse (PN) should report to the registered nurse (RN) for further investigation if any of the following assessment abnormalities occur in a neonate: Head circumference <32 cm or >37 cm: A neonate's normal head circumference is 32-37 cm. The RN should assess a neonate with a smaller or larger head circumference (Option 3). Jaundice: This is not a normal finding in a neonate, especially during the first 24 hours when it is always pathological. The RN should assess the neonate further to determine the cause (Option 4). No voiding in 24 hours: Neonates should void and pass meconium within 24 hours after delivery. If they do not, this could indicate a structural anomaly (Option 5). Nasal flaring, chest wall retractions, and grunting with respirations: These are a sign of respiratory distress (Option 1). (Option 2) Flaking or peeling skin, known as desquamation, is a normal finding in neonates. Moisturizers can be applied to the neonate's skin to resolve this. Educational objective: The PN should inform the RN of abnormal assessment findings that require further evaluation. When assessing neonates, the PN should report abnormal head circumference (<32 cm or >37 cm), presence of jaundice, failure to void or pass meconium within 24 hours, and any signs of respiratory distress (eg, nasal flaring, grunting, retractions).

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds 2. Contraction frequency of every 3 minutes 3. Contraction intensity of 45 mm Hg 4. Uterine resting tone of 10 mm Hg

1. Contraction duration of 95 seconds Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity.

After giving birth to a full-term neonate, the client tells the practical nurse, "I have been taking hydrocodone on a regular basis for several years." The practical nurse collaborates with the registered nurse to include which intervention in the neonate's plan of care? 1. Feed newborn while swaddled 2. Keep newborn close to the nurse's station 3. Position newborn supine after feeding 4. Stimulate newborn with light regularly

1. Feed newborn while swaddled A neonate born to a woman dependent on opioids (eg, heroin, methadone, hydrocodone) is at high risk for neonatal abstinence syndrome, in which the newborn experiences opioid withdrawal typically within 24-48 hours after birth. Withdrawal symptoms affect primarily the central nervous (eg, irritability, jitteriness, high-pitched crying), autonomic nervous (eg, stuffy nose, sweating), and gastrointestinal (eg, diarrhea, vomiting, poor feeding) systems. Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying position while swaddled to minimize stimulation and promote nutritive sucking (Option 1). Between feedings, a pacifier may be used to soothe the infant and help establish an organized sucking pattern. Excessive movement places the newborn at high risk for skin excoriation; the infant should be swaddled tightly with arms flexed to minimize irritation and prevent skin damage. Hand mittens and barrier skin protection to the knees, elbows, and heels may also be used. (Options 2 and 4) Stimulation should be avoided due to the newborn's hypersensitive state; the newborn should be placed in a quiet, dimly lit section of the nursery. The nurse should also organize tasks ("cluster care") to minimize stimulation. (Option 3) The newborn should be placed on the right side after feeding to promote gastric emptying and reduce the risk of aspiration if vomiting occurs. Educational objective: An infant born to an opioid-dependent mother is at risk for neonatal abstinence syndrome. Withdrawal symptoms affect primarily the central nervous (eg, jitteriness, irritability), autonomic nervous (eg, stuffy nose, sweating), and gastrointestinal (eg, poor feeding, diarrhea) systems. Nursing care is focused on reducing stimulation and promoting nutrition and comfort.

A client denies illicit drug use but has some suspicious behaviors. The client's neonate has a low birth weight. What other signs would lead the nurse to suspect neonatal abstinence syndrome? Select all that apply. 1. Irritability and restlessness 2. Meconium ileus and floppy tone 3. Microencephaly and cleft palate 4. Poor feeding and loose stools 5. Stuffy nose and frequent sneezing

1. Irritability and restlessness 4. Poor feeding and loose stools 5. Stuffy nose and frequent sneezing Manifestations include: Autonomic nervous system symptoms - stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and tachypnea. Treatment includes swaddling and keeping nasal passages clear (Option 5). Central nervous system symptoms - irritability, restlessness, high-pitched crying, abnormal sleep pattern, and hypertonicity/hyperactive primitive reflexes. Treatment includes medication and protecting the skin (Option 1). Gastrointestinal symptoms - poor feeding, vomiting, and diarrhea. These are treated with small, frequent feedings (Option 4). (Option 2) Meconium ileus is classic for cystic fibrosis, a genetic disorder. Floppy muscle tone is typical for Down's syndrome, a genetic disorder. (Option 3) These signs are from exposure to teratogenic agents, especially during the first 8 weeks of gestation. Microcephaly is an effect of fetal alcohol syndrome or cytomegalovirus infection. Craniofacial defects, including cleft lip and palate (eg, congenital anomalies), can be caused by maternal anticonvulsant use (eg, valproic acid). Opioids are not teratogenic.

if the FHR tracing shows a non-reassuring pattern (late decelerations, fetal bradycardia, tachycardia, and decreased variability), interventions are performed in the following order:

1. Stop oxytocin immediately - this will stop uterine stimulation and should be the nurse's first action 2. Immediately notify the registered nurse (RN) who will contact the health care provider (HCP) 3. Reposition or maintain the side-lying position - this is a simple and effective measure to decrease aortocaval compression and increase placental blood flow 4. Give IV fluid bolus under direction of the RN 5. Apply oxygen at 10 L/min via face mask - only if steps 1, 3, and 4 do not reduce abnormalities. Administering oxygen will be more helpful if there is adequate placental perfusion of the oxygenated blood. Maternal repositioning and IV fluid administration should therefore be performed before oxygen administration. Document the findings

When is fetal heart heart able to be detected by Doppler?

10-12 weeks

A couple is excited about finding out the sex of their baby during ultrasound at 14 weeks gestation. What is the nurse's best response? 1. "Basic structures of major organs are not yet formed." 2. "External genitalia are not usually visualized until 21-24 weeks." 3. "If the baby is in the right position, the genitalia may be visualized." 4. "Sex cannot be determined until fetal movement is felt."

3. "If the baby is in the right position, the genitalia may be visualized." By the end of 12 weeks gestation, fetal sex can often be determined by the appearance of the external genitalia on ultrasound, depending on the quality of the image. (Option 1) By the end of 8 weeks gestation, all major organ systems are in place, and many are functioning in a simple way. By 7 weeks gestation, fetal heart tones can be detected. (Options 2 and 4) Clients typically begin feeling fetal movements in the second trimester at around 16-20 weeks gestation. Parous (have been pregnant before) clients can notice this earlier than the nulliparous (first pregnancy). Fetal sex can be determined as early as the end of 12 weeks gestation. Educational objective: Fetal heart tones can be detected by 7 weeks gestation. Fetal sex may be determined on ultrasound as early as the end of 12 weeks gestation. Fetal movements are typically felt at around 16-20 weeks gestation.

Postpartum pyschosis

2 weeks postpartum Symptoms Hallucinations, delusions, impulsivity, hyperactivity, confusion, delirium; often associated with bipolar disorder Treatment Emergent psychiatric hospitalization, pharmacologic intervention

Postpartum blues

2-3 days postpartum, resolves in 2 weeks Symptoms emotional lability, mild sadness, irritability, insomnia Treatment supportive care, client & family education, ongoing assessment for worsening

Normal uterine contractions

2-5 contractions in 10 minutes, should not occur more frequently than every 2 minutes

A nurse is reinforcing information on formula preparation for a client with a newborn. Which statements by the client indicate proper understanding? Select all that apply. 1. "I can add water to the formula if my baby wants to eat more frequently." 2. "I must wash the top of the concentrated formula can before opening it." 3. "I shouldn't heat formula in the microwave for more than 1 minute." 4. "If my baby does not finish the bottle, the leftover milk should be refrigerated." 5. "Prepared formula should be kept in the refrigerator and discarded after 48 hours."

2. "I must wash the top of the concentrated formula can before opening it." 5. "Prepared formula should be kept in the refrigerator and discarded after 48 hours." Parents should also adhere to basic guidelines for safe storage and handling. Key teaching points include: Keep bottles, nipples, caps, and other parts as clean as possible, either by boiling or washing in the dishwasher. Wash the tops of formula cans prior to opening to prevent contamination (Option 2). - Refrigerate prepared formula or opened cans of ready-to-feed or concentrated formula and discard after 48 hours if unused (Option 5). There is a risk of bacterial growth after this time. - Warm prepared bottles by placing in a pan of hot water for several minutes. - Never microwave formula as it can cause mouth burns (Option 3). - Test temperature on the inner wrist before serving to the infant; the formula should feel lukewarm, but never hot. (Option 1) Formula should never be diluted or concentrated. Dilution of the formula does not allow the infant to receive the appropriate amount of calories, vitamins, and minerals needed for normal growth and development. Overconcentration of the formula can cause excessive proteins and minerals to be ingested that exceed the excretory ability of the infant's immature kidneys. (Option 4) Any formula left in a bottle after a feeding should be discarded immediately because the infant's saliva has mixed with it, which encourages bacterial growth.

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply. 1. Angle bottle up and toward cleft 2. Burping the infant often 3. Feeding in an upright position 4. Feeding slowly over 45 minutes or more 5. Using a specialty bottle or nipple

2. Burping the infant often 3. Feeding in an upright position 5. Using a specialty bottle or nipple A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option 4) Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth.

The nurse is reviewing the chart of a pregnant client at 10 weeks gestation during the first prenatal appointment. Which finding indicates that client teaching is needed? 1. Client gained 4 lb (1.8 kg) since pre-pregnancy 2. Client has a pet dog and cat at home 3. Client has thin, milky white vaginal discharge 4. Client swims in the pool 3 times a week

2. Client has a pet dog and cat at home Toxoplasmosis is a disease due to Toxoplasma gondii, a parasite that infects humans via cat feces or ingestion of undercooked meat. In a normal healthy adult, the infection goes unnoticed (no symptoms or only flulike symptoms are present) and causes no long-term damage. However, in a pregnant client, the parasite can be passed from mother to baby in utero and can cause significant damage to the growing fetus. If toxoplasmosis is acquired during pregnancy, it can cause stillbirth or serious fetal malformations. Pregnant clients should be advised to stay away from a litter box or cat feces to reduce toxoplasmosis risk.

Which findings in a newborn are considered abnormal and should be reported to the registered nurse? Select all that apply. 1. Cyanosis of the hands and feet 2. Decreased muscle tone 3. Heart rate of 150/min 4. Sacral dimple 5. Single artery in the umbilical cord

2. Decreased muscle tone 4. Sacral dimple 5. Single artery in the umbilical cord Hypotonia, or decreased muscle tone, may be related to hypoxia, Down syndrome, or a muscular/neurologic disorder (Option 2). A sacral dimple may be a sign of spina bifida occulta, a defect in which the bones that protect the meninges and spinal cord fail to close during gestation (Option 4). A normal umbilical cord contains 2 arteries and 1 vein. The presence of a single umbilical artery is sometimes associated with congenital defects, particularly of the kidneys and heart (Option 5). Acrocyanosis is cyanosis of the hands and feet that results from poor peripheral blood perfusion as an initial mechanism to reduce heat loss and stabilize temperature. It is considered normal during the first day of life or up to 7-10 days after birth if the infant becomes cold.

A client at 21 weeks gestation has intense heartburn (pyrosis). What should the nurse recommend? Select all that apply. 1. Avoid dairy products 2. High-protein, low-fat diet 3. Lie on the left side after meals 4. Six small meals a day 5. Sodium bicarbonate antacid

2. High-protein, low-fat diet 4. Six small meals a day Pyrosis, also known as heartburn, occurs during pregnancy from an increase in the hormone progesterone. Progesterone causes the esophageal sphincter to relax, leading to pyrosis. Interventions to reduce heartburn include: Upright position after meals to reduce gastroesophageal reflux Small, frequent meals rather than 3 large meals a day (Option 4) Keeping the head of the bed elevated using pillows Drinking smaller amounts of fluid while eating Eliminating dietary triggers, including fried and fatty foods, caffeine/chocolate, spicy foods, carbonated drinks, and peppermint (Option 2) (Option 1) Dairy products do not lead to heartburn and should not be avoided during pregnancy. Clients should avoid fried and fatty foods, coffee, and carbonated beverages. (Option 3) Clients should stay upright 2-3 hours after meals. Lying down immediately after eating will cause heartburn to increase and lead to more discomfort. (Option 5) Most antacids are safe during pregnancy. However, those containing sodium bicarbonate (Alka-Seltzer) or magnesium trisilicate should be avoided during pregnancy. Educational objective: Heartburn (pyrosis) is caused by the hormone progesterone, which causes the esophageal sphincter to relax. Methods the pregnant client can take to reduce pyrosis include maintaining an upright position after meals, eating small meals, taking approved antacids, and avoiding causative foods and beverages.

A client at 34 weeks gestation has constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which instructions should the nurse reinforce for this client? Select all that apply. 1. Decrease total daily dairy intake 2. Increase intake of fruits and vegetables 3. Moderate-intensity regular exercise 4. One laxative twice daily for a week 5. Two cups of hot coffee each morning

2. Increase intake of fruits and vegetables 3. Moderate-intensity regular exercise Interventions to prevent or treat constipation include: High-fiber diet: High amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes High fluid intake: 10-12 cups of fluid daily Regular exercise: Moderate-intensity exercise (eg, walking, swimming, aerobics) Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin (Option 1) Dairy is a great source of calcium, which is essential for fetal bone development. However, dairy products should be consumed at least 2 hours before or 1 hour after iron supplements as they bind to iron and decrease absorption. (Option 4) Laxatives are not recommended during pregnancy due to the risk of dehydration and electrolyte imbalance, which can lead to uterine cramping and contractions. The client should consult with the health care provider before using any over-the-counter stool softeners or laxatives. (Option 5) Caffeine consumption in pregnancy should be limited to 200-300 mg/day. Coffee may contain 100-200 mg caffeine per cup and should therefore be consumed in moderation during pregnancy. Educational objective: Constipation in pregnancy may be caused by increased progesterone levels and iron supplementation. It is best treated with 10-12 cups of fluid daily, a high-fiber diet/supplementation, and regular exercise. Clients should not take laxatives without first discussing this with the health care provider.

A nurse is reinforcing teaching to a breastfeeding client who has been diagnosed with mastitis of the right breast. Which instructions should be included? Select all that apply. 1. Cease breastfeeding from right breast 2. Increase oral fluid intake 3. Reduce frequency of feeds to every 8 hours in right breast 4. Take ibuprofen as needed for pain 5. Use underwire bra 24 hours a day for support

2. Increase oral fluid intake 4. Take ibuprofen as needed for pain Mastitis is a common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage (eg, poor latch). Bacteria are transmitted from the infant's nasopharynx or the mother's skin through the nipple and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema). In addition to antistaphylococcal antibiotics (dicloxacillin or cephalexin) and analgesics (eg, ibuprofen), treatment of lactational mastitis requires effective and frequent milk drainage. Milk ducts are most efficiently drained by direct breastfeeding while ensuring a proper latch. Adequate rest and increased oral fluid intake are also recommended. (Options 1 and 3) Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mothers should be reassured that the infant can feed safely from the infected breast as the newborn is already colonized with the mother's skin flora. (Option 5) Underwire bras (tight bras) are not recommended with breastfeeding or mastitis as milk flow is impeded, worsening engorgement. Soft cup bras are recommended for support and to encourage milk flow. Educational objective: Treatment of lactational mastitis includes antibiotic therapy, breast support, adequate hydration, analgesics, and frequent (every 2-3 hours) continued breastfeeding.

A practical nurse is collaborating with the registered nurse to form a care plan for a client diagnosed with placenta previa at 33 weeks gestation. What does the nurse anticipate being included in the plan of care? Select all that apply. 1. Activity as tolerated 2. Nonstress test 1 or 2 times a week 3. Prepare for cesarean birth at any time 4. Type and screen blood 5. Vaginal examinations twice weekly

2. Nonstress test 1 or 2 times a week 3. Prepare for cesarean birth at any time 4. Type and screen blood (Option 1) The recommended activity for a client at less than 36 weeks gestation with diagnosed placenta previa is bed rest with bathroom privileges. A stable client may be released to continue bed rest at home, but the client must be closely monitored and return to the hospital immediately if bleeding occurs. (Option 5) Clients with placenta previa are placed on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of hemorrhage. Clients with placenta previa are at risk for hemorrhage. Bed rest with bathroom privileges is recommended for clients at less than 36 weeks gestation. A nonstress test or biophysical profile should be performed once or twice a week to evaluate fetal well-being. Pelvic rest is instituted to prevent disruption of the cervix. A cesarean birth is planned prior to onset of labor.

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantar creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins

2. Plantar creases up the entire sole 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins

The practical nurse is collecting data on several clients in the antepartum unit. Which client should the practical nurse report to the registered nurse for further assessment? 1. 24 weeks gestation, 1-hour glucose screen is 120 mg/dL 2. 25 weeks gestation, hemoglobin is 9 g/dL 3. 30 weeks gestation, nonstress test is reactive 4. 36 weeks gestation, white blood cell count is 13,000/mm3

25 weeks gestation, hemoglobin is 9 g/dL Iron deficiency anemia is a common complication during pregnancy. It is related to low iron stores and diets low in iron. During pregnancy, clients are diagnosed with iron deficiency anemia when their hemoglobin level is <11 g/dL in the first and third trimesters and <10.5 g/dL in the second trimester. A client with a hemoglobin level of 9 g/dL should be evaluated for additional signs of iron deficiency anemia (eg, fatigue, dizziness, tachycardia, tachypnea). Treatment involves increasing dietary iron and folate, along with iron supplementation (usually 325 mg ferrous sulfate tid).

Normal uterine contractions intensity

25-50 mmhg, should not exceed 80 mmhg

A nurse is caring for a pregnant client who has hyperemesis gravidarum. Which findings should the nurse anticipate? Select all that apply. 1. Blood pressure of 160/94 mm Hg 2. Large amounts of urine protein 3. Positive urine ketones (moderate) 4. Potassium of 3.2 mEq/L (3.2 mmol/L) 5. Pulse rate of 106/min

3. Positive urine ketones (moderate) 4. Potassium of 3.2 mEq/L (3.2 mmol/L) 5. Pulse rate of 106/min Hyperemesis gravidarum (HG) is severe, persistent nausea and vomiting during pregnancy. Excessive loss of gastric contents leads to fluid and electrolyte imbalances (eg, hypokalemia, hyponatremia), metabolic alkalosis, nutritional deficiencies, ketonuria, and weight loss (Option 4). The nurse would expect signs and symptoms of dehydration (eg, dry mucous membranes, poor skin turgor, decreased urine output, tachycardia) (Option 5). Urine is concentrated with dehydration, indicated by increased specific gravity (>1.030). Ketonuria indicates that the body is breaking down fat to use for energy due to the client's starvation state (Option 3). (Option 1) Clients with HG are typically dehydrated, and low blood pressure would be expected due to hypovolemia. (Option 2) Proteinuria is not caused by HG but is associated with kidney disease or preeclampsia. Educational objective: Hyperemesis gravidarum (ie, excessive vomiting during pregnancy) leads to fluid and electrolyte imbalances (eg, hypokalemia), weight loss, nutritional deficiencies, and ketonuria. Signs and symptoms of dehydration include poor skin turgor, decreased urine output, tachycardia, low blood pressure, and dry mucous membranes.

The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching? 1. "I can expect the cord to turn black in a few days." 2. "I should let the cord fall off by itself." 3. "I will give my newborn sponge baths until the cord falls off." 4. "I will secure the diaper over the cord to protect it."

4. "I will secure the diaper over the cord to protect it." Explanation: The umbilical cord is clamped immediately after birth. This clamp is removed after the cord stops bleeding and begins to dry, usually around 24 hours after birth. The remaining cord stump will begin to shrivel and turn black within 2-3 days (Option 1). It will then separate from the umbilicus around 1-2 weeks after birth. Proper care of the umbilical cord stump facilitates healing and reduces infection risk. The primary goal of cord care is to keep the stump dry and clean. Key principles of cord care include: Keep the cord open to air whenever possible to allow for adequate drying Give the newborn sponge baths with warm water. Tub baths should be avoided until the cord has fallen off (Option 3). Promptly dry the cord stump if it comes into contact with fluid Keep diapers folded below the cord to keep it dry and prevent contamination with urine or feces (Option 4) Allow the cord to fall off on its own, even if it is barely attached (Option 2). Attempts to pull the cord off may result in bleeding or other complications. Report any signs of infection (eg, redness, purulent drainage, swelling) to the health care provider Educational objective: The primary goal of cord care is to keep the stump dry and clean. Sponge baths should be given until the umbilical cord falls off in approximately 1-2 weeks. Diapers should be folded beneath the cord to keep it dry and avoid contamination.

A pregnant client comes to the labor and delivery unit stating the water just broke at home. On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure 2. Perform Leopold maneuvers 3. Perform the McRoberts maneuver 4. Position the client on hands and knees

4. Position the client on hands and knees Umbilical cord prolapse occurs when the umbilical cord slips below the presenting fetal part and may cause cord compression and impaired fetal oxygenation. A loop of cord may be palpated during a vaginal examination or visualized protruding from the vagina. An emergency cesarean section is usually required unless vaginal birth is imminent and considered safe by the health care provider (HCP). Positioning the client on hands and knees (eg, knee-chest position) or Trendelenburg position is used to relieve pressure on the compressed cord (Option 4). The nurse may also use a sterile, gloved hand to help lift the presenting part off the cord; the hand should remain in the vagina until the HCP arrives. Other actions include administration of oxygen and IV fluids. A client with a prolapsed umbilical cord should be placed on hands and knees (eg, knee-chest position) or Trendelenburg position to relieve pressure on the cord until emergency delivery.

A nurse is measuring the uterine fundal height of a client who is at 36 weeks gestation in supine position. The client suddenly reports dizziness and the nurse observes pallor and damp, cool skin. What should the nurse do first? 1. Auscultate for heart and lung sounds 2. Determine fetal heart rate and pattern 3. Notify the supervising registered nurse 4. Reposition client into a lateral position

4. Reposition client into a lateral position Supine hypotensive syndrome occurs when the weight of the abdominal contents compresses the vena cava, causing decreased venous return to the heart. This results in low cardiac output (maternal hypotension) and reflex tachycardia. Manifestations include dizziness, pallor, and cold and clammy skin. The client should be repositioned onto the right or left side immediately until the symptoms subside. The client should be placed in the supine position with a wedge placed under the hip to prevent this condition. (Option 1) When supine hypotension is suspected, the client first should be placed in a lateral position. Blood pressure and pulse are checked to confirm the diagnosis. Assessing for lung and heart sounds is not a priority. (Option 2) Decreased maternal cardiac output can result in decreased placental blood flow and fetal heart rate (FHR) abnormalities. FHR assessment is also performed after the client is placed in the right or left lateral position. (Option 3) The supervising registered nurse should be notified, but after the client is placed in a lateral position and assessed completely. Educational objective: Supine hypotensive syndrome is usually seen in the third trimester of pregnancy when the weight of the uterine contents compresses the inferior vena cava. Resultant maternal hypotension is best treated initially by immediately turning the client to the right or left side to relieve pressure on the vena cava.

Weight gain during pregnancy

According to recommendations made by the Institute of Medicine in 2009, weight gain during pregnancy should be determined by prepregnancy BMI. Underweight clients need to gain more weight (1 lb [0.5 kg]/wk) during the second and third trimesters of pregnancy than do obese clients (0.5 lb [0.2 kg]/wk). However, weight gain in the first trimester should be 1.1-4.4 lbs (0.5-2.0 kg) regardless of BMI. With a prepregnancy BMI of 21 kg/m2, this client is classified as an appropriate-weight client and should gain 25-35 lb (11.3-15.9 kg).

APGAR scale

Appearance - 0 is pale/blue all over - 1 blue extremities - 2 is body and extremities pink Pulse - 0 is heart rate absent - 1 is heart rate below 100 - 2 is heart rate above 100 Grimace - 0 is absence of response to stimulation - 1 is feeble cry or grimace after stimulation - 2 is cry of pulls away after stimulation Muscle tone - 0 is none - 1 is some flexion - 2 is flexed arms and legs that can resist extension Respiration - 0 is absent - 1 is weak and irregular - 2 is strong cries

The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse? 1. Discomfort during fundal palpation 2. Foul-smelling lochia 3. Oral temperature 100.1 F (37.8 C) [10%] 4. White blood cell count 24,000/mm3 (24.0 x 109/L)

Foul-smelling lochia A foul odor of lochia suggests endometrial infection. This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical examinations. The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness. (Option 1) Palpation of the postpartum uterine fundus is commonly uncomfortable. If the client has increasing pain, further evaluation is needed. (Option 3) Major signs and symptoms of endometrial infection include temperature >100.4 F (38.0 C), chills, malaise, excessive uterine tenderness, and purulent, foul-smelling lochia. During the first 24 hours postpartum, temperature is normally elevated, but a reading of >100.4 F (38 C) requires further evaluation. (Option 4) The white blood cell count is normally elevated during the first 24 hours postpartum (up to 30,000/mm3 [30.0 x 109/L]). Leukocyte levels that are not decreasing require further evaluation. Educational objective: Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and white blood cell count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation.

Intervention for Meconium Aspiration Syndrome

Infant should be intubated and meconium should be sanctioned

Phases of labor

Latent - onset to 4 cm dilation - contractions 15-30 mins apart, 15-30 seconds long Active - 4 to 7 cm dilation - contractions 3-5 min part, 30-60 secs long transition - 8 cm to fully dilated/10cm - contractions 2-3 min apart, 45-90 secs long

A client at 39 weeks gestation with preeclampsia has a blood pressure of 170/100 mm Hg, 2+ proteinuria, and moderate peripheral edema. Immediately after hospital admission, she develops seizures and uterine contractions. Magnesium sulfate is prescribed. Which finding indicates that the drug has achieved the desired therapeutic effect? 1. Blood pressure <130/80 mm Hg [30%] 2. Seizure activity stops [47%] 3. Urine has 1+ protein [3%] 4. Uterine contractions stop [18%]

Preeclampsia is a systemic disease characterized by hypertension and proteinuria after the 20th gestational week with unknown etiology. Eclampsia is the onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia. Delivery is the only cure for preeclampsia-eclampsia syndrome. Option 1) Hypertension is a sign of preeclampsia. Hydralazine (Apresoline), methyldopa (Aldomet), or labetalol (Trandate) is used to lower blood pressure (BP) if needed (usually considered when BP is >160/110 mm Hg). (Option 3) Proteinuria is a symptom of preeclampsia. Control of hypertension and delivery will reduce the protein level. Magnesium sulfate is not prescribed to decrease proteinuria. (Option 4) Tocolytic drugs (eg, terbutaline, magnesium sulfate, indomethacin, nifedipine) are used to suppress uterine contractions in preterm labor, allowing pregnancy to be prolonged for 2-7 days so that corticosteroid administration can improve fetal lung maturity. This client is at term, and there is no need to delay delivery. Educational objective: Magnesium sulfate is prescribed for clients with preeclampsia to prevent seizure activity. A therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic client. Magnesium sulfate is a central nervous system depressant used to prevent/control seizure activity in preeclampsia/eclampsia clients. During administration, the nurse should assess vital signs, intake and output, and monitor for signs of magnesium toxicity (eg, decreased deep-tendon reflexes, respiratory depression, decreased urine output). A therapeutic magnesium level of 4-7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic client.

Babinkinsi

The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect.

A pregnant client provides the following obstetric history to the nurse at the first prenatal visit: Elective abortion at age 17; a 5-year-old daughter born at 40 weeks gestation; and 3-year-old twin boys born at 34 weeks gestation. Using the GTPAL system, which option is correct? 1. G3, T1, P1, A1, L3 2. G3, T1, P2, A1, L3 3. G4, T1, P1, A1, L3 4. G4, T1, P2, A1, L3

The GTPAL system is a shorthand system of documenting a client's obstetric history. Under this system, twins, triplets, or other multiple births count as one in the term (T) or preterm (P) category but are counted separately (as 2, 3, or more) in the living child (L) category. A current pregnancy (not yet delivered), as in this client, counts in the gravida (G) category as this category includes all pregnancies, past and present. In this scenario, the client is a G4 T1 P1 A1 L3. She is gravida (G) 4 as she has a history of 4 pregnancies (which includes the present pregnancy) (Option 3). The client delivered a child at 40 weeks gestation (counts 1 in the term [T] category). She delivered twins at 34 weeks gestation, reflected as a single birth (1 pregnancy) in the preterm (P) category and as 2 living children in the living child (L) category. She had an elective abortion, reflected as 1 in the abortion (A) category. She has a total of 3 living children (1 term and 2 preterm children), reflected in the living child (L) category. Under the GTPAL system, G - gravida indicates the number of pregnancies, delivered or undelivered; T - term deliveries are from 37 wk 0 days and beyond; P - preterm deliveries are from 20 wk 0 days to 36 wk 6 days gestation; A - abortions (spontaneous or elective) occur prior to 20 wk 0 days gestation; and L - living children are counted individually regardless of multiple birth status.

Uterine Atony

characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early PPH (occurring ≤24 hours after birth). Delayed PPH (>24 hours after birth) usually results from retained placental fragments associated with a long third stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes).

Signs of endometritis

cramping uterine tenderness purulent, foul smelling loch

Stages of pregnancy

first stage - starts onset of regularly perceived uterine contractions and ends with full cervical dilation second stage - reached full dilation and already lies at +2 Third stage - expulsion of the infant and ends with delivery of placenta Fourth stage - placenta explosion to 1-4 hours postpartum