maternity evolve

A nurse identifies a right cephalhematoma on an otherwise healthy 1-day-old newborn. What should the nurse teach the parents at the time of discharge? 1 How to monitor their child for signs of jaundice 2 To space feedings at every 3 hours 3 How to assess the fontanels for tenseness 4 To record the number of wet diapers during the first 24 hours

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n infant's intestines are sterile at birth and therefore lacking the bacteria necessary for the synthesis of: 1 Bilirubin 2 Bile salts 3 Prothrombin 4 Intrinsic facto

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A nurse is caring for a newborn with a cephalohematoma. What is the priority nursing action? 1 Supporting the parents 2 Recording neurologic signs 3 Protecting the infant's head 4 Applying ice packs to the hematoma

1 Parents need support and reassurance that their newborn is not permanently damaged. Cephalohematomas do not cause impaired neurologic function. No special protection of the head is required; routine safety measures are adequate. Cephalohematomas resolve spontaneously; ice is not applied.

A client has a cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day? 1 Providing oxygen therapy 2 Administering pain medication 3 Encouraging frequent ambulation 4 Recommending an increase in oral fluids

3 Ambulation involves muscle contractions that promote an increase in circulation in the legs. During pregnancy, hypercoagulation is associated with an increase in clotting factors and fibrinogen, which increases the risk for thromboembolism. Oxygen therapy will not prevent thromboembolism. Relieving pain does not prevent thromboembolism, but pain medication may be needed to help the client tolerate ambulation. Increasing fluid intake will not prevent thromboembolism.

A pregnant woman with a history of heart disease visits the prenatal clinic at the end of her second trimester. What does the nurse anticipate about the care she will need? Preparation for a cesarean birth 2 Bedrest during the last trimester 3 Prophylactic antibiotics at the time of birth 4 Increasing dosages of cardiac medications as pregnancy progresses

3 antibiotics for bact endocarditis

A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. What should the nurse tell the client to do? 1 Pant while pushing gently. 2 Breathe with her mouth closed. 3 Hold her breath while bearing down. 4 Pant while resisting the urge to bear down

4 Panting prevents the mother from putting pressure on the fetal head by pushing. The nurse applies gentle pressure against the fetus's head as it emerges to prevent a precipitous birth, which could result in central nervous system injury to the fetus and vaginal lacerations in the mother. It is impossible to pant and push at the same time. Breathing with the mouth closed promotes the bearing-down reflex. Bearing down during the birth is unsafe because both fetus and mother could be injured.

A breastfeeding mother experiences redness and pain in the left breast, a temperature of 100.8° F (38.2° C), chills, and malaise. What condition does the nurse suspect? 1 Mastitis 2 Engorgement 3 Blocked milk duct 4 Inadequate milk production

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newborn with acquired herpes simplex virus infection is being discharged. Which facet of development should the nurse teach the parents to monitor? 1 Visual clarity 2 Renal function 3 Long bone growth 4 Responses to sounds

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lient arrives in the birthing unit from the emergency department with blood running down both legs and a low blood pressure. What is the primary intervention? 1 Assessing fetal heart tones 2 Assessing for a prolapsed cord 3 Starting an intravenous infusion 4 Inserting a uterine pressure catheter

1 The priority is determining fetal viability, because it will determine the next intervention. Assessing the client for a prolapsed cord is not the priority. An intravenous line will be inserted, but it is not the priority. Inserting a pressure catheter might increase the bleeding; it will not yield useful information.

left sacroposterior LSP

breech head not in pelvic

A client required an extensive episiotomy because her newborn was large. What is a priority nursing intervention that minimizes edema and lessens discomfort at the episiotomy site? 1 Applying ice packs to the perineum 2 Positioning the client off the incisional area 3 Administering an oral analgesic to the client 4 Spraying the perineum with a local anestheti

1Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. A side-lying position will not lessen pain or reduce edema. Analgesia may diminish the pain but will not lessen the edema. An anesthetic spray is not used after an episiotomy.

strict vegetarian (vegan) becomes pregnant and asks the nurse whether there is anything special she should do in regard to her diet during pregnancy. What is most the important measure for the nurse to instruct the client to take? 1 Eat at least 40 g/day of protein. 2 Drink at least 1 quart/day of milk. 3 Take a vitamin supplemented with iron every day. 4 Plan to eat from specific groups of vegetable proteins each day.

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A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? 1 Gravida III with twins 2 Gravida V with endometriosis 3 Gravida II who had a 9-lb baby 4 Gravida I who has had an intrauterine fetal death

4 Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and high birthweight are not risk factors for DIC.

A nurse in the birthing unit is caring for several clients. Which factor should the nurse know will increase the risk for hypotonic uterine dystocia? 1 Twin gestation 2 Gestational anemia 3 Hypertonic contractions 4 Gestational hypertension

1 A multiple gestation thins the uterine wall by overstretching it; therefore the efficiency of contractions is reduced. Gestational anemia is physiologic anemia that is benign; although anemia may cause fatigue during labor, it does not affect uterine contractility. Hypertonic contractions will cause increased discomfort, fatigue, dehydration, and increased emotional distress, not hypotonic uterine dystocia. Therapeutic interventions include rest and sedation. Gestational hypertension may trigger preterm labor; it does not cause hypotonic uterine dysfunction.

A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score? 1 Start resuscitation. 2 Administer oxygen. 3 Place in a heated crib. 4 Stimulate by tapping the toes

1 An Apgar score of 3 indicates a severely depressed newborn with apnea, slow heart rate, and an absence of reflexes; resuscitation should be ongoing and should have been started before 1 minute had elapsed. A patent airway must be established before oxygen is administered. Although thermoregulation is important, establishing a patent airway and initiating respiration are of greater importance. Stimulation efforts are ineffective for a neonate who requires resuscitative measures.

A client at 26 weeks' gestation is admitted to the high-risk unit with an influenza infection. She is in labor. Which of these instructions should a nurse question? 1 Betamethasone 12 mg IV every 12 hours 2 I&O and IV Ringer's lactate 500 mL/24 hours 3 Vital signs and fetal heart rate every 30 minutes 4 Loading dose 4 g IV magnesium sulfate, continue per protocol

1 Antenatal glucocorticoid therapy is contraindicated when the client has an active infection and there is no risk of premature delivery. An available IV line should be maintained, as should monitoring of intake and output (I&O). Maternal vital signs and fetal heart rate every 30 minutes is the usual protocol for monitoring the vital signs during preterm labor. Measures to halt labor should be started.

pregnant client's last menstrual period was on February 11. A physical assessment on July 18 should reveal the top of the fundus: 1 Even with the umbilicus 2 Just above the symphysis pubis 3 Two fingerbreadths above the umbilicus 4 Halfway between the symphysis and umbilicus

1 Around the 22nd week of gestation the top of the fundus is at the level of the umbilicus. Just above the symphysis pubis is too low for a pregnancy between the fifth and sixth months of gestation. Two fingerbreadths above the umbilicus is too high for 20 to 22 weeks' gestation. Halfway between the symphysis pubis and umbilicus is too low for a pregnancy between the fifth and sixth months of gestation.

A client in active labor is considering combined spinal-epidural analgesia (CSE). She states that she is concerned about her ability to walk after receiving this type of analgesia. What is the most accurate response by the nurse? 1 "This analgesia gives you pain relief without compromising your ability to ambulate." 2 "The analgesia will require you to remain in bed, but you'll be able to move from side to side." 3 "You may experience slight weakness, but someone will be at your side when you're ambulating." 4 "Someone will help you ambulate every couple of hours before you're given another dose of the analgesia."

1 Because the spinal nerve receptors are sensitive to opioids, small quantities are needed to produce analgesia; therefore the client's ability to ambulate without assistance is not jeopardized. Bedrest is not required. The analgesia does not cause weakness. The client's ability to ambulate without assistance is not jeopardized. The analgesia lasts for more than 2 hours; there is no need to ambulate before a dose is given.

During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. What should the nurse do? 1 Rewarm gradually. 2 Notify the practitioner. 3 Assess for hyperglycemia. 4 Record skin temperature hourly

1 Gradually rewarming an infant experiencing cold stress is essential to avoid compromising the infant's cardiopulmonary status. It is not necessary to notify the practitioner initially. It is the nurse's responsibility to rewarm the infant. An infant experiencing cold stress will become hypoglycemic because glycogen and glucose are metabolized to maintain the core temperature. Skin temperature should be taken at least every 15 minutes until stable.

What should be included in nursing care immediately after a sexual assault? 1 Obtaining the assault history from the client 2 Informing the police before the client is examined 3 Having the client void a clean-catch urine specimen 4 Testing the client's urine for seminal alkaline phosphatase

1 Obtaining the assault history from the client provides a basis for assessing trauma; in a client of childbearing age it also is necessary to assess the risk for pregnancy. Examination may precede reporting; the decision to report is mandated by law. Urination may wash away spermatic or bloody evidence. A test for seminal acid phosphate, not seminal alkaline phosphatase, is performed.

A 26-year-old G1 P0 is seen in the clinic for her routine prenatal visit at 29 weeks' gestation. On examination the nurse notes that she has gained 8 lb since her last visit, 2 weeks ago; that her blood pressure is 150/90 mm Hg, and that she has 1+ proteinuria on urine dipstick. What is the likely diagnosis for this client? 1 Mild preeclampsia 2 Severe preeclampsia 3 Chronic hypertension 4 Gestational hypertension

1 Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply. 1 "My ears are ringing." 2 "It gets better when I lie down." 3 "Bright lights really bother my eyes." 4 "It gets better as soon as I walk a while." 5 "My head hurts more when I'm sitting watching TV." 6 "My head hurts more when I'm lying on my side breastfeeding

135 Central nervous system irritation can cause auditory problems such as tinnitus. A headache resulting from spinal anesthesia usually occurs 24 to 72 hours after administration. Postural changes cause the diminished volume of cerebrospinal fluid to exert traction on pain-sensitive central nervous system structures. The client is most comfortable when lying flat. Central nervous system irritation can cause visual problems such as photophobia and blurred vision. This type of headache will worsen when the client is ambulatory or assumes an upright position.

What is the nurse's priority assessment for a client in the fourth stage of labor? 1 Degree of relaxation 2 Distention of the bladder 3 Extent of breast engorgement 4 Presence of mother-infant bonding

2 A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric. It is too soon to assess breast engorgement because it occurs on the third or fourth postpartum day. It is too soon to assess bonding; this progresses with care and responsibility.

A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. What does the nurse suspect precipitated this preterm labor? 1 Android pelvis 2 Incompetent cervix 3 First-time pregnancy 4 Antiseizure medication

2 An incompetent cervix indicates a short cervix, cervical scarring from previous births, or cervical or uterine anomalies. It puts the client at risk for second-trimester miscarriage. An android pelvis is more likely to cause dystocia than preterm labor. A woman who has had a previous preterm labor, not a primigravida, is at risk for recurrence. Clients with epilepsy who are taking antiseizure medications are at risk for perinatal mortality rather than preterm labor.

When the fetal head begins to crown during an emergency precipitous birth, the nurse responds by: 1 Pressing firmly on the fundus 2 Applying gentle perineal pressure 3 Encouraging the client to push forcefully 4 Telling the client to take prolonged deep breaths

2 Applying gentle perineal pressure prevents too-rapid expulsion of the head, which can lead to perineal laceration in the mother. Pressing firmly on the fundus is contraindicated; a precipitate birth is caused by forceful uterine contractions that expel uterine contents. Pushing may cause too-rapid expulsion and perineal laceration. At this time the urge to push is uncontrollable; the client will be unable to take prolonged deep breaths. Topics

A client at 36 weeks' gestation is admitted to the high-risk unit because she gained 5 lb in the previous week and there is a pronounced increase in blood pressure. What is the initial intervention in the client's plan of care? 1 Preparing for an imminent cesarean birth 2 Providing a dark, quiet room with minimal stimuli 3 Initiating intravenous furosemide to promote diuresis 4 Administering calcium gluconate to lower the blood pressure

2 Increasing cerebral edema may predispose the client to seizures; therefore stimuli of any kind should be minimized. It is too early to plan for a cesarean birth; other therapies will be tried first. The client will probably be given IV magnesium sulfate to prevent a seizure, not furosemide to promote diuresis. Magnesium sulfate will be used; calcium gluconate is its antidote.

small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect? 1 Hypovolemia 2 Hypoglycemia 3 Hypercalcemia 4 Hypothyroidism

2 SGA infants may exhibit signs of hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. Decreased blood pressure, pallor with cyanosis, tachycardia, retractions, lethargy, and a weak cry are signs of hypovolemia. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.

he parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed? 1 Heel stick 2 Buccal smear 3 Urinary catheterization 4 Venous blood withdrawal2

2 The cells in the buccal smear provide a pictorial analysis of chromosomes and show chromosomal abnormalities such as the trisomy found in Down syndrome. Blood from the heel stick is tested for inborn errors of metabolism such as phenylketonuria. Urine is not used to assess chromosomal aberrations; neither is venous blood.

During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect, and what suggestion is made to correct the problem? 1 Hypercalcemia; avoid eating hard cheeses. 2 Hypocalcemia; increase her intake of milk. 3 Hyperkalemia; consult her health care provider. 4 Hypokalemia; increase intake of green leafy vegetables.

2 The most likely cause is a disturbance in the ratio of calcium to phosphorus, with the amount of serum calcium reduced and the serum phosphorus increased; milk and other dairy products are excellent sources of calcium. Leg cramps are related to hypocalcemia, not to hypercalcemia. An increased potassium level manifests as muscle weakness. A low potassium level is evidenced by fatigue and muscle weakness.

wo days after giving birth a client's temperature is 101° F (38.3° C). A nurse notifies the health care provider and receives a variety of prescriptions. In what order should they be implemented? 1. Obtain a chest x-ray. 2. Send a lochia specimen for culture. 3. Administer the prescribed intravenous antibiotic. 4. Assess and document the client's temperature 30 minutes after administering the medications. 5. Offer the as-needed acetaminophen (Tylenol) for a fever more than 100° F (37.7° C).

23514 Prioritize care according to Maslow's hierarchy of needs and the nursing process. A culture specimen should be obtained before antibiotics are given to ensure that the antibiotic does not interfere with accurate culture results. The antibiotic is the most important of these prescriptions and should be given as soon as possible to counteract any infective processes, but it should not be administered before the specimen is obtained for the culture. The acetaminophen (Tylenol) is a comfort measure that may be administered at any time, but does not take precedence over the antibiotic, however, it would facilitate pain relief prior to obtaining a chest x-ray which would require additional movement and possibly increased discomfort. Arranging for a chest radiograph will not interfere with implementation of any of the other prescriptions; it may take time to schedule a radiograph. The client's response to the acetaminophen should have lowered the client's temperature within 30 minutes.

In her 36th week of gestation, a client with type 1 diabetes has a 9-lb 10-oz infant in a cesarean birth. For which condition should the nurse monitor this infant of a diabetic mother? 1 Meconium ileus 2 Physiologic jaundice 3 Respiratory distress syndrome 4 Increased intracranial pressure

3 A large-for-gestational-age infant born at 36 weeks' gestation to a mother with diabetes may have immature lung tissue, which predisposes the newborn to respiratory distress. Meconium ileus is suggestive of cystic fibrosis, which is unrelated to maternal diabetes. Physiologic jaundice manifests about 24 hours after birth, when fetal red blood cells begin to be subjected to hemolysis; this is unrelated to maternal diabetes. Increased intracranial pressure may be associated with birth injury or hydrocephalus; it is unrelated to maternal diabetes.

A 37-year-old woman agrees to have a prenatal test done to diagnose fetal defects. There is a history of Down syndrome in her family, and this is her first pregnancy. Which invasive prenatal test provides the earliest diagnosis and rapid test results? 1 Nonstress test 2 Amniocentesis 3 Chorionic villus sampling 4 Percutaneous umbilical blood sampling

3 Chorionic villus sampling may be performed between 10 and 12 weeks' gestation. Amniocentesis may be performed after 14 weeks' gestation, when sufficient amniotic fluid is available. Direct access to the fetal circulation with percutaneous umbilical blood sampling may be performed during the second and third trimesters. The nonstress test, which is not invasive, is a technique used for antepartum evaluation of the fetus; it does not reveal fetal defects.

What should nursing care for the affected arm of an infant born with Erb-Duchenne paralysis (brachial palsy) include? 1 Keeping it immobilized 2 Measuring the length of the arm daily 3 Teaching the parents to manipulate the arm muscles 4 Starting passive range-of-motions exercises immediatel

3 Gentle massage and manipulation of the arm muscles help prevent contractures. The parents can perform these activities at home. Keeping the arm immobilized is dangerous because this may lead to the development of permanent contractures. The length of the arm will not change on a daily basis. Passive range-of-motion exercises should be delayed for 10 days to prevent additional injury to the brachial plexus.

primigravida asks the nurse, "I've got this blotchy skin on my face, my nipples are darker, and there's this dark line down the middle of my stomach. What causes that?" The nurse explains that the gland that causes these expected changes during pregnancy is the: 1 Adrenal gland 2 Thyroid gland 3 Anterior pituitary gland 4 Posterior pituitary gland

3 Hypersecretion of melanocyte-stimulating hormone (MSH) from the anterior pituitary gland causes darkened pigmentations during pregnancy. MSH is not secreted by the adrenal glands, thyroid gland, or posterior pituitary gland.

What is the most common complication for which a nurse must monitor preterm infants? 1 Hemorrhage 2 Brain damage 3 Respiratory distress 4 Aspiration of mucus

3 Immaturity of the respiratory tract in preterm infants is evidenced by a lack of functional alveoli, smaller lumina with increased possibility of collapse of the respiratory passages, weakness of respiratory musculature, and insufficient calcification of the bony thorax, leading to respiratory distress. Hemorrhage is not a common occurrence at the time of birth unless trauma has occurred. Brain damage is not a primary concern unless severe hypoxia occurred during labor; it is difficult to diagnose at this time. Aspiration of mucus may be a problem, but generally the air passageway is suctioned as needed.

A nurse teaches a couple about care of their newborn, who has been circumcised. The nurse concludes that the teaching is effective when the father says: 1 "We shouldn't expect fussy behavior." 2 "We should leave the baby undiapered." 3 "We should apply petrolatum gauze to the penis." 4 "We should notify the clinic if we see a yellow discharge."

3 Petrolatum gauze helps control bleeding and prevents adherence to the diaper. Fussy behavior is expected for a few hours after the procedure. Leaving the baby undiapered is not practical with a male infant. Yellow exudate is expected; it is not a sign of an infectious process.

A primigravida is admitted with a ruptured fallopian tube resulting from a tubal pregnancy and surgery is performed to remove the fallopian tube. What should postoperative nursing care include? 1 Counseling on how to prevent another tubal pregnancy 2 Administering Rho (D) immune globulin to prevent isoimmunization 3 Explaining that the client may still be capable of becoming pregnant 4 Telling the client to avoid douching after intercourse because this may dislodge a fertilized egg

3 Removing a fallopian tube does not impair the ovaries' ability to release an egg, which may be fertilized in the remaining tube if it is undamaged. There is no known way to prevent future tubal pregnancies. There is no information to indicate that the client is Rh negative, requiring the administration of Rho (D) immune globulin (RhoGAM). Liquid from a douche does not reach the fallopian tube or dislodge a fertilized egg; in addition, douching is no longer recommended.

A nurse is assessing a newborn with a diaphragmatic hernia. What does the nurse expect to identify? 1 Diarrheal stools 2 Enlarged abdomen 3 Barrel-shaped chest 4 Abdominal breath sounds

3 The chest is barrel shaped because of the protrusion of abdominal viscera through the defect into the thoracic cavity. Diarrhea is not associated with a diaphragmatic hernia; usually there is colicky pain and constipation. The abdomen is markedly scaphoid (sunken). There are no breath sounds over the abdomen.

wo hours after a client gives birth, her physical assessment findings include a blood pressure of 86/40 mm Hg; temperature/pulse/respirations of 98/100/22; a firm fundus, four fingerbreadths above the umbilicus; small spots of lochia rubra on the perineal pad; and a distended bladder. After a urinary catheterization the client's fundus remains firm and four fingerbreadths above the umbilicus. What should the nurse do next? 1 Catheterize the client again. 2 Palpate the client's fundus every 2 hours. 3 Notify the client's health care provider immediately. 4 Recheck the client's vital signs in 30 minutes

3 The practitioner should be notified because the increased height of the uterus may be due to accumulation of blood in the uterus caused by internal hemorrhaging. Also, the blood pressure is low and the pulse is rapid, possibly indicating impending shock. Another intervention will delay the immediate, urgent response that is needed because the client may be hemorrhaging.

A nurse is assessing a newborn whose mother had a precipitate birth at home. For which complication should the nurse assess the newborn? 1 Facial palsy 2 Dislocated hip 3 Fractured clavicle 4 Intracranial hemorrhage

4 A rapid birth does not give the fetal head adequate time for molding, so pressure against the head is increased, which may result in intracranial hemorrhage. Facial palsy (paralysis) is caused by pressure on the facial nerve during birth. This is the result of a prolonged second stage of labor or a forceps birth; it does not occur during a precipitous birth. A dislocated hip is more likely to occur in a footling breech birth. A fractured clavicle may occur if pulling on the shoulders during the birth is required.

When a client's legs are being placed in stirrups for birth, the nurse ensures that the left and right legs are positioned simultaneously to help prevent: 1 Venous stasis in the legs 2 Pressure on the perineum 3 Excessive pull on the fascia 4 Trauma to the uterine ligaments

4 As the uterus rises into the abdominal cavity, the uterine ligaments become elongated and hypertrophied; raising both legs at the same time limits the tension placed on these ligaments. Lifting the legs simultaneously does not affect circulation in the legs. Pressure is already being exerted on the perineum by the head of the fetus; this maneuver eases tension on the uterine ligaments. This maneuver has no effect on the fascia.

To prevent or stabilize a client in heroin withdrawal during labor, which medication should be administered as ordered if the woman is nauseated, vomiting, or did not receive her daily dose at a chemical dependence center? 1 Butorphanol (Stadol) 2 Pentazocine (Talwin) 3 Nalbuphine (Nubain) 4 Dolophine (Methadone)

4 Methadone is a narcotic analgesic used to prevent withdrawal symptoms in pregnant women who have stopped using heroin or other opioid drugs. Butorphanol, pentazocine, and nalbuphine are all narcotic agonist-antagonists and may cause acute withdrawal symptoms in the woman and fetus.

What type of lochia should the nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? 1 Scant alba 2 Scant rubra 3 Moderate rubra 4 Moderate serosa

4 On the third to fourth day the uterine discharge becomes pink to brown; it continues until approximately the 10th day. After about 10 days the uterine discharge becomes yellow to white (alba); alba may continue until 2 to 6 weeks after the birth. It is unusual to have scant lochia rubra. Lochia rubra lasts from the first to about the third day; it is usually heavy but may be moderate after a few days

A client in the high-risk postpartum unit had a precipitous labor and birth. What maternal complication should the nurse anticipate? 1 Hypertension 2 Hypoglycemia 3 Chilling and shivering 4 Bleeding and infection

4 Precipitate birth is associated with an increased maternal morbidity rate because hemorrhage and infection may occur as a result of the trauma of a rapid, forceful birth in a contaminated field. Hypertension is anticipated in a client with preeclampsia. There are not enough data to indicate that this client has preeclampsia. A low blood glucose level is not expected after a precipitous birth. Chilling and shivering are common maternal responses after all types of births because of cardiovascular and vasomotor changes.

newborn has an intracranial hemorrhage because of a tear in the tentorial membrane sustained during birth. Which clinical finding does the nurse expect the infant to display? 1 Extreme lethargy 2 Weak, timorous cry 3 Generalized purpura 4 Abnormal breathing pattern

4 Tears in the tentorial membrane result in bleeding into the cerebellum, pons, or medulla oblongata; because the respiratory regulation centers are located in the medulla and pons, an abnormal breathing pattern may result. Lethargy is more indicative of cerebellar injury. A weak, timorous cry is more indicative of cardiac or respiratory difficulty; a high-pitched, shrill cry is usually present with central nervous system (CNS) problems. Purpura is unrelated to tentorial or other CNS injuries.

client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client? 1 Increased blood pressure and pulse 2 Reduction of pain in the perineal area 3 Gradual cervical dilation as labor progresses 4 Decreased frequency and duration of contractions

4 Terbutaline sulfate (Brethine) is a β-mimetic that acts on the smooth muscles of the uterus to reduce contractility, which in turn inhibits dilation and the frequency and duration of contractions. Although terbutaline may increase blood pressure and pulse, this is a side, not a therapeutic, effect requiring frequent assessments. Terbutaline is not an analgesic. It should stop cervical dilation rather than increase it.

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity? 1 Humidifying oxygen flow to prevent dehydration 2 Uncovering the entire body to increase exposure to the oxygen 3 Applying eye patches to both eyes to protect them from the oxygen 4 Verifying oxygen saturation frequently to adjust flow on the basis of need

4Determining oxygen saturation identifies the need for oxygen supplementation; prolonged use of oxygen concentrations exceeding those required to maintain adequate oxygenation contributes to the occurrence of retinopathy of prematurity. Preventing dehydration by humidifying the oxygen will not prevent retinopathy of prematurity. The skin does not absorb oxygen; it must enter the lungs through inhalation. Retinopathy of prematurity is caused by a high blood concentration of oxygen, not by exposure of the eyes to oxygen.

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time? 1 Documenting the heart rate 2 Initiating a feeding immediately 3 Placing the infant in a heated crib 4 Assessing the heart rate again in an hour

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t 35 weeks' gestation a client has an amniocentesis to determine fetal lung maturity. What should the nurse do first to detect complications immediately after the procedure? 1 Assess the fetal heart rate. 2 Assess for fetal movement. 3 Obtain the maternal vital signs. 4 Apply pressure at the puncture site

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A client at 28 weeks' gestation visits the clinic for a routine examination. Which of the following is of greatest concern to the nurse? 1 Puffy fingers 2 Glycosuria 1+ 3 Proteinuria 1+ 4 Dependent edema

1 One sign of mild preeclampsia is puffiness of the fingers, eyes, and face. Glycosuria is a common finding in pregnancy; an increased glomerular filtration rate in conjunction with decreased capacity of the tubules to reabsorb glucose may cause spillage of glucose into urine. Minimal proteinuria may occur in a healthy pregnancy; the amount of protein that must be filtered exceeds the ability of the tubules to absorb it, causing small amounts to be lost in the urine. Venous obstruction from the gravid uterus decreases blood flow to the heart; as a result, fluid pools in the lower extremities; this is expected.

A client in labor is admitted to the birthing unit 20 hours after her membranes rupture. What complication should the nurse anticipate when assessing the character of the client's amniotic fluid? 1 Cord prolapse 2 Placenta previa 3 Maternal sepsis 4 Abruptio placentae

3 Prolonged rupture of membranes more than 18 hours earlier increases the risk of maternal and newborn sepsis. The amniotic fluid must be assessed for color, viscosity, and odor; thick, yellow-stained, cloudy fluid with a foul odor indicates infection. Cord prolapse usually occurs shortly after the membranes rupture; it is unlikely that it will occur 20 hours after the membranes have ruptured. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Abruptio placentae is premature separation of a normally implanted placenta; it, too, is unrelated to ruptured membranes.

A mother who notes that her newborn regurgitates after feedings asks the nurse whether her baby is ill. What should the nurse consider before responding? 1 It is caused by a spasm of the pyloric valve. 2 It is caused by the infant's position after feeding. 3 An underdeveloped cardiac sphincter causes regurgitation.

3 The cardiac sphincter of the newborn is not fully developed; if the stomach is too full, the feeding backs up through the sphincter and the infant regurgitates. A spasm of the pyloric valve is marked by projectile vomiting, not by regurgitation. Basing the answer on the infant's position is too vague; the position is not described. Swallowing air while suckling may cause cramping or colic.

A client in labor, who is at term, is admitted to the birthing room. The fetus is in the left occiput posterior position. The client's membranes rupture spontaneously. What observation requires the nurse to notify the practitioner? 1 Greenish amniotic fluid 2 Shortened intervals between contractions 3 Clear amniotic fluid with specks of mucus 4 Maternal temperature of 99.1° F (37.3° C)

1 Greenish amniotic fluid indicates the presence of meconium and should be reported to the health care provider. The interval between contractions should shorten as labor progresses. Clear fluid with specks of mucus is the description of normal amniotic fluid. There may be a slight increase in temperature related to the stress of labor, and it should be monitored.

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk developing jaundice. Which conditions are risk factors for jaundice? Select all that apply. 1 Infection 2 Female sex 3 Prematurity 4 Breastfeeding 5 Formula feeding 6 Maternal diabetes

1346 Infants are at a higher risk of jaundice if they are born prematurely, are exclusively breastfed, have an infection, or their mothers have diabetes. Jaundice is more common in male infants. Infants that are fed formula do not develop jaundice as often as breastfeed babies do.

new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply. 1 Thin upper lip 2 Wide-open eyes 3 Small upturned nose 4 Larger-than-average head 5 Smooth vertical ridge in the upper lip

135 The abnormal facies associated with FAS includes a thin upper lip (vermilion), a small upturned nose, and a smooth vertical ridge (philtrum) in the upper lip, all of which are distinctive in these infants. Infants with FAS have small eyes with epicanthic folds, rather than wide-open eyes, as well as microcephaly (head circumference less than the tenth percentile), rather than a larger-than-average head.

The nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Where does the nurse look for extra skinfolds? 1 Calf muscles 2 Popliteal area 3 Back of the thigh 4 Lower portion of the abdomen

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A nurse is planning for the discharge of a crack-addicted 17-year-old mother and her newborn. What is the most appropriate referral to meet the mother's and infant's needs? 1 Legal aid 2 Family court 3 Foster parent care 4 Home health nurse

4

Despite medication, a client's preterm labor continues, her cervix dilates, and birth appears inevitable. Which medication does the nurse anticipate will be prescribed to increase the chance of the newborn's survival? 1 Ritodrine (Yutopar) 2 Misoprostol (Cytotec) 3 Terbutaline (Brethine) 4 Betamethasone (Celestone

4 Betamethasone (Celestone) enhances fetal lung maturity when administered before a preterm birth. Ritodrine (Yutopar) and Terbutaline (Brethine) are tocolytic agents used to prevent preterm birth; this birth is inevitable. Misoprostol (Cytotec) is used for labor induction.

During a routine examination at the prenatal clinic the nurse notes significant increases in the client's blood pressure and edema of the face and hands. The diagnostic criterion for preeclampsia is a blood pressure of 140/90 mm Hg, but what is the lowest blood pressure that should prompt the nurse to monitor the client for other signs and symptoms of preeclampsia? 1 130/85 mm Hg 2 125/80 mm Hg 3 115/75 mm Hg 4 110/70 mm Hg

1

A client who is at 33 weeks' gestation has contracted gonorrhea and is prescribed probenecid (Benemid) and penicillin. What instructions will the nurse give to the client regarding the reason for dual therapy? 1 "Your allergy to penicillin is minimized." 2 "The side effects of the disease are reduced." 3 "Your immune defense mechanisms are more active." 4 "The amount of penicillin in your blood is increased.

4 Probenecid (Benemid) reduces renal tubular excretion of penicillin. The other options are unrelated to the concomitant administration of penicillin and probenecid.

A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. Select all that apply. 1 Sleep needs increase. 2 Fluid retention increases. 3 Body temperature decreases. 4 Calcium requirements increase. 5 The need for carbohydrates decreases.

124 Estrogen increases the secretion of corticosteroids, which decrease the basal metabolic rate, resulting in fatigue. Sodium is retained, and fluid retention increases to meet total needs. During the first trimester approximately 1.2 g of calcium is needed each day; this need continues throughout pregnancy as the fetal skeleton is being formed. Body temperature increases because of the increased metabolism related to the growth of the fetus. Carbohydrate needs increase because the secretion of insulin by the pancreas is increased; however, insulin is destroyed rapidly by the placenta. The stress of pregnancy may precipitate gestational diabetes.

What clinical finding does the nurse expect when assessing a client with abruptio placentae? 1 Flaccid uterus 2 Painless bleeding 3 Boardlike abdomen 4 Bright red bleeding

3 Extravasation of blood at the placental separation site into the myometrium causes a tetanic boardlike uterus. The uterus is rigid because it is filled with blood and clots. Painless bleeding is associated with placenta previa; abdominal pain and uterine tenderness occur with abruptio placentae. In abruptio placentae the bleeding is not bright red; usually it is a port wine color.

A nurse is monitoring a client with severe preeclampsia for the onset of eclampsia. What clinical finding indicates an impending seizure? 1 Persistent headache with blurred vision 2 Epigastric pain with nausea and vomiting 3 Spots and flashes of light before the eyes 4 Rolling of the eyes to one side with a fixed stare

4 Rolling of the eyes to one side with a fixed stare is a sign of central nervous system involvement that the nurse can see without obtaining subjective data from the client. It is a sign of an impending seizure. Persistent headache with blurred vision, epigastric pain with nausea and vomiting, and spots and flashes of light before the eyes are all clinical manifestations of severe preeclampsia, not eclampsia.

A nurse who is caring for a postpartum client is concerned because the woman is at risk for hemorrhage. Which factor in the client's history alerted the nurse to this concern? 1 Multifetal pregnancy 2 Short duration of labor 3 Previous cesarean birth 4 Age greater than 40 year

1

client in preterm labor does not respond to therapy, and birth seems imminent. The client begins to cry and says, "I'm so worried about my baby." What is the nurse's best response? 1 "All of this must leave you very confused and frightened." 2 "Think positively; your anxiety will increase your contractions." 3 "You're getting the best medical and nursing care available." 4 "This hospital has a neonatal unit, and it can handle emergencies like your

1

A primigravida is concerned about the health of her baby and asks the nurse, "What is the most common cause of death in babies?" The nurse explains that the cause of more than half of the neonatal deaths in the United States is: 1 Atelectasis 2 Preterm birth 3 Congenital heart disease 4 Respiratory distress syndrome

2

After a difficult labor a client gives birth to a 9-lb boy who dies shortly afterward. That evening the client tearfully describes to the nurse her projected image of her son and what his future might have been. What is the nurse's most therapeutic response? 1 "I guess you wanted a son very much." 2 "It must be difficult to think of him now." 3 "I'm sure he would have been a wonderful child." 4 "If you dwell on this now, your grief will be harder to bear."

2

A mother is breastfeeding her newborn. She asks a nurse when she can safely switch her baby to a cup. At what age should the nurse recommend that this be done? 1 1 year 2 1½ years 3 4 months 4 6 months

4

While performing patterned, paced breathing during the transition phase of labor, a client experiences tingling and numbness of the fingertips. What should the nurse do? 1 Tell the client to breathe into a paper bag. 2 Place an oxygen mask over the client's face. 3 Call the practitioner to report the client's response. 4 Instruct the client to begin taking slow deep breaths

1 A paper bag enables the client to rebreathe carbon dioxide, which helps correct the respiratory alkalosis resulting from hyperventilation. The client's oxygen level is increased; the client needs to increase the carbon dioxide level and decrease the oxygen level. The client should rebreathe her own exhalations first; if alkalosis persists, more intensive treatment may be needed. Carbon dioxide is too dilute in room atmosphere; deep breaths will not resolve the alkalosis.

Laboratory studies reveal that a pregnant client's blood type is O and she is Rh-positive. Problems related to incompatibility may develop in her infant if the infant is: 1 Rh-negative 2 Type A or B 3 Born preterm 4 Type O and Rh-positive

2 An ABO incompatibility may develop even in firstborn infants because the mother has antibodies against the antigens of the A and B blood cells; these antibodies are transferred across the placenta and produce hemolysis of the fetal red blood cells; if the infant were AB, an incompatibility might also occur. Problems will not occur if the mother is Rh-positive and the infant is Rh-negative. A preterm birth will not produce an incompatibility; it may intensify problems if an incompatibility exists. If the infant is the same type and has the same Rh factor as the mother, there is no incompatibility.

After a client's membranes rupture spontaneously, the nurse sees the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority. 1. Administer oxygen to the mother and monitor fetal heart tones. 2. Call for assistance and don sterile gloves. 3. Insert two fingers into the vagina and exert upward pressure against the fetal presenting part. 4. Put a rolled towel under one hip and place in the modified Sims position.

2314

After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond? 1 "I'm going to take your temperature right now." 2 "Let me check your uterus to see whether it's firm." 3 "Turn on your side so I can check the amount of lochia." 4 "I'll get you some warm blankets to help make the chill go away."

4 A postpartum chill is an expected vasomotor reaction; covering the client with warm blankets will ease the discomfort. Taking the client's temperature, palpating the uterus, and monitoring the lochial flow are all parts of the routine postpartum assessment but do not ne

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period? 1 Bradycardia with no change in respirations 2 Tachycardia with a decrease in respirations 3 Increased basal temperature with a decrease in respirations 4 Decreased basal temperature with an increase in respirations

1 In the postpartum period a slow pulse rate may result from a combination of factors, including decreased cardiovascular workload, emotional relief and satisfaction, and rest after labor and birth. Bradycardia is more likely; respirations generally are unchanged. The temperature may rise slightly, but usually respirations are unchanged.

A 40-year-old multigravida's pregnancy is confirmed at 8 weeks' gestation. She says, "I can't wait another 2 months for an amniocentesis to find out whether my baby has a chromosomal anomaly like my first child." The nurse responds that she can have chorionic villus sampling between the 10th and 12th weeks because if it is performed before this time: 1 It can cause fetal anomalies. 2 The results are not as accurate. 3 The information it provides is inadequate. 4 It must be done with the use of laparoscopic surgery

1 The American Congress of Obstetricians and Gynecologists recommends that chorionic villus sampling (CVS) not be performed before 9 weeks' gestation and should be performed between 10 to 12 weeks. Performed before 9 weeks' gestation, it has the potential of interfering with organogenesis. The test, if successfully performed, is 100% accurate, and it provides enough information for a diagnosis. A laparoscopic procedure is not necessary because CVS is performed either by means of transcervical catheter aspiration or transabdominal needle aspiration.

While receiving betamimetic (tocolytic) therapy for preterm labor the client begins to experience muscle tremors and exhibit signs of nervousness. She reports, "My heart is racing." The nurse identifies that the client's pulse rate is 110 beats/min and regular. What should the nurse do next? 1 Discontinue the medication as per protocol. 2 Notify the practitioner that preterm labor has restarted. 3 Obtain the client's laboratory results for electrolyte levels. 4 Reassure the client that these are expected side effects of the medication.

4 Beta-mimetics have the unpleasant side effects of nervousness, tremors, and palpitations; clients should be informed that these side effects are expected. If contractions are lessened and the maternal heart rate is less than 120 and regular, the medication is performing as expected and does not need to be discontinued. Muscle tremors and palpitations are not signs and symptoms of preterm labor. Electrolyte levels are unrelated to these side effects of the tocolytic agent

What should the nurse explain to a newly pregnant client with cardiac disease? 1 Palpitations are expected as pregnancy progresses. 2 Other cardiac medications will be substituted for digoxin. 3 It is not safe to administer prophylactic penicillin during pregnancy. 4 Maintenance dosages of cardiac medications will probably be increased.

4 During the second and third trimesters blood volume and cardiac output increase, placing a greater workload on the heart. Women with preexisting heart disease may require larger doses of cardiac medication to prevent cardiac decompensation. Palpitations may occur when the heart rate reaches 120 beats/min. A heart rate of more than 100 beats/min may be an indicator of cardiac decompensation; further assessment and treatment are required. Digoxin (Lanoxin) is a category C medication and is prescribed during pregnancy. Penicillin is a category B medication and is relatively safe to take during pregnancy.

A nurse is caring for a pregnant woman with class II cardiac disease. The client has anemia with a hemoglobin level of 8 g/dL. What is the nurse's major concern for this client? 1 Impending heart failure 2 Development of heart block 3 Appearance of atrial fibrillation 4 Imminent ventricular fibrillation

1 Anemia decreases the capacity of the blood to carry oxygen and thus increases demands on the heart. Heart block is due to a disturbance in the conduction of impulses, not the oxygen-carrying capacity of blood. Cardiac irregularity is not associated with anemia. Imminent ventricular fibrillation is a grave complication; adequate treatment should prevent this.

A nurse is caring for a 42-year-old client who is scheduled for an amniocentesis during the 15th week of gestation because of concerns about Down syndrome. What other fetal problem does an examination of the amniotic fluid reveal at this time? 1 Diabetes 2 Lung maturity 3 Cardiac anomalies 4 Errors of metabolism

4 Inherited errors of metabolism may be detected if marker genes for the disease, such as Tay-Sachs and thalassemia, are present. Fetal diabetes and cardiac disorders cannot be detected with amniocentesis. Fetal lung maturity cannot be determined until after 35 weeks' gestation.

What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? Select all that apply. 1 Smoker 2 Twin gestation 3 Hemoglobin of 12 g/dL 4 Term delivery 2 years ago 5 Caffeine intake of 180 mg/day 6 Fasting blood sugar of 80 mg/dL

12

A sonogram performed on a client in the third trimester demonstrates a low-lying placenta. The nurse should teach the client that she is at risk for: 1 Sharp abdominal pain 2 Painless vaginal bleeding 3 Increased lower back pain 4 Early rupture of membranes

2

An almost term client reports that her fetus is moving less this week than last week. Which responses are appropriate? Select all that apply. 1 "Don't worry—the fetus sleeps a lot near the end of the pregnancy." 2 "It would be good for you to come to labor and delivery to be evaluated today." 3 "Always call the health care provider if you're worried that your baby isn't moving enough." 4 "Let me teach you how to conduct a kick count, and then you can call me when you've done one."

234

A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? Select all that apply. 1 Prone 2 Sitting 3 Supine 4 Lateral 5 Knee-chest

245

At 12 weeks' gestation a client with a history of frequent spontaneous abortions says to the nurse, "Every day I wonder whether I'll be able to have this baby." How should the nurse respond? 1 "I can understand why you're worried, but you'll have other chances in the future to get pregnant." 2 "You're getting the best of care. Please tell me about the problems with your previous pregnancies." 3 "It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time." 4 "Your pregnancy has lasted past the time when most early miscarriages occur. I think you'll be able to continue the pregnancy."

3

The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members? 1 Escherichia coli 2 Group B Streptococcus 3 Staphylococcus aureus 4 Chlamydia trachomatis

3

A neonate born at 32 weeks' gestation and weighing 3 lb (1360 g) is admitted to the neonatal intensive care unit. The nurse should take the neonate's mother to visit the infant when the: 1 Infant's condition has stabilized 2 Infant is out of immediate danger 3 Practitioner has written an order permitting it 4 Mother is well enough to be taken to the intensive care uni

4

A client who is at 38 weeks' gestation is admitted to the birthing unit because her membranes ruptured 24 hours ago and contractions have started. The fetus is in a breech presentation. The nurse observes that the amniotic fluid is green. What does the nurse conclude from these findings? 1 The fetus has a neural tube defect. 2 Fetal well-being is compromised. 3 Intrauterine infection has developed. 4 Meconium is being expelled with contractions

4 In a breech presentation, the pressure of the contractions on the fetus's lower abdomen causes meconium to be expelled into the amniotic fluid with each contraction. Meconium in the amniotic fluid is not a sign of a neural tube defect, regardless of presentation. Greenish amniotic fluid does not indicate a compromised fetus if there is a breech presentation. The data do not indicate signs of malodorous amniotic fluid or maternal pyrexia, each of which is indicative of infection.

What should the nurse's initial discussion include to best help new parents understand the unique characteristics of a newborn? 1 Auditory and visual acuity 2 Expected movements and behaviors 3 The need for parent-infant attachment 4 The need to establish a feeding schedule

4 Information on typical behaviors helps parents understand the unique features of their newborn and promotes interaction and appropriate care. Auditory and visual acuity is too limited; the parents need a broader discussion of infant behaviors. Although important, this can best be fostered if parents know what behaviors to expect from their infant. Need to establish a feeding schedule is too limited; in addition, most infants are on a demand feeding schedule, which fosters individuality.

A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. What value denotes a healthy infant? 1 Less than 40% 2 More than 75% 3 Between 45% and 65% 4 Between 65% and 75%

3

A nurse is assessing a newborn with trisomy 21 (Down syndrome). What clinical findings does the nurse expect? Select all that apply. 1 Large, round eyes 2 Difficulty hearing 3 Protruding tongue 4 Hypotonic muscle tone 5 Two creases across the palm 6 Broad nose with a depressed bridge

346 The eyes appear small because of epicanthic folds on the inner corner of the eyelids and the upward slant of the eyes. Impaired hearing is not an expected problem with Down syndrome. The tongue usually protrudes and is sometimes fissured. Infants with Down syndrome have decreased muscle tone, which compromises respiratory expansion, as well as the adequate drainage of mucus. Usually there is one deep crease across the palm of the hand (simian crease). A broad nose with a depressed bridge (saddle nose) is a characteristic of Down syndrome.

client at 24 weeks' gestation arrives at the clinic for a routine examination. She tells the nurse, "I feel puffy all over." In light of this statement, what is the nurse's most important assessment? 1 Obtaining her blood pressure 2 Determining how much salt she uses 3 Asking the extent of her daily fluid intake 4 Reviewing her history for total weight gai

1 Increased blood pressure is suggestive of preeclampsia, especially if the client has anasarca (generalized edema). Sodium and fluid intake are both unrelated to the development of preeclampsia. Sudden, not total, weight gain is suggestive of preeclampsia.

What assessment finding should the nurse consider a concern in a client at 35 weeks' gestation? 1 Frequent painless urination 2 Painful intermittent contractions 3 Increased fetal movement after eating 4 Lower back pain that results in insomnia

2 Painful contractions at this time may indicate preterm labor or the presence of preparatory contractions (formerly called Braxton Hicks contractions), although preparatory contractions may be painless or painful. The client's painful intermittent contractions must be assessed further to distinguish between the two types. Frequent urination is common during the last trimester because of the pressure of the enlarging fetus; painful urination may indicate a urinary tract infection. Fetal movement usually increases after the mother eats. Difficulty sleeping and lower back pain are both common adaptations during the third trimester.

A nurse is admitting a pregnant client who has mitral valve stenosis to the high-risk unit. What prophylactic medication does the nurse anticipate administering during the intrapartum period? 1 Diuretic 2 Antibiotic 3 Cardiotonic 4 Anticoagulant

2 Clients who have mitral valve stenosis are administered prophylactic antibiotic therapy to minimize the development of streptococcal infections that may cause endocarditis. A diuretic will probably be used if heart failure develops. A cardiotonic will probably be used if heart failure develops. An anticoagulant will probably be used if thrombophlebitis or atrial fibrillation develops.

What should the nurse recommend to a new mother when teaching her about the care of the umbilical cord area? 1 Remove the cord clamp only after the cord stump has separated. 2 Leave the area untouched or clean with soap and water, then pat it dry. 3 Smooth ointment or baby lotion around the cord after the sponge bath. 4 Wrap an elastic bandage snugly around the waist area over the cord site

2 Healing is optimal when the area is left alone or, if needed, is washed with mild soap and water and then gently dried. The cord clamp is removed when the cord stump is dry, usually at 24 hours. Ointment and other emollients will keep the cord moist; rapid drying of the cord is preferred. Wrapping an elastic bandage snugly around the waist area over the cord site prevents the cord from drying and provides a dark, warm, moist medium for the growth of organisms.

A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? Select all that apply. 1 Fever 2 Seizures 3 Deafness 4 Conjunctivitis 5 Cardiac anomalies

35\ Depending on the specific period of organogenesis when the mother contracted rubella, a variety of defects may occur. Deafness is a typical sign of a newborn affected by a mother who had rubella during early pregnancy. Cardiac anomalies are common in newborns if the mother had rubella during pregnancy during the time of organogenesis. Fever is expected if the mother had an active herpes simplex virus infection or toxoplasmosis at the time of a vaginal birth. Central nervous system problems occur when the mother had toxoplasmosis or an active herpes simplex infection during pregnancy. Conjunctivitis is found in newborns whose mothers had gonorrhea or Chlamydia during a vaginal birth.

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn? 1 Naloxone (Narcan) 2 Lorazepam (Ativan) 3 Meperidine (Demerol) 4 Promethazine (Phenergan)

3

An infant is admitted to the nursery after a difficult shoulder birth. For what condition should the nurse assess this newborn? 1 Facial paralysis 2 Cephalhematoma 3 Brachial plexus injury 4 Spinal cord syndrom

3 Brachial plexus paralysis (Erb-Duchenne palsy) is the most common injury associated with dystocia related to a shoulder presentation; it is caused by pressure and traction on the brachial plexus during the birth process. The newborn's face is not involved with a shoulder presentation. Cephalhematoma is a soft-tissue injury of the head and is not related to shoulder dystocia. Spinal cord syndrome is associated with a breech presentation and is not related to shoulder dystocia.

he nurse, teaching a client in early pregnancy about the need to increase her intake of complete proteins, asks the client to identify foods that contain these proteins. Which response indicates that client understands the teaching? Select all that apply. 1 Spinach and broccoli 2 Milk, eggs, and cheese 3 Beans, peas, and lentils 4 Fish, hamburger, and chicken 5 Whole-grain cereals and breads

24 Milk, eggs, and cheese are complete proteins containing all nine indispensable (essential) amino acids. Likewise, fish, hamburger, and chicken are complete proteins containing all nine indispensable (essential) amino acids. Plant proteins are incomplete proteins. Whole-grain cereals and breads are incomplete proteins, and they contain comparatively small amounts of protein.

When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs? 1 During early adolescence 2 Throughout the entire pregnancy 3 When she is planning to become pregnant 4 At the beginning of the first trimester

3

A nurse is caring for a client in labor whose fetus is in the breech presentation. For what complication should the nurse monitor the client? 1 Hemorrhagic shock 2 Increased blood pressure 3 Compression of the cord 4 Meconium in the amniotic fluid

3 The cord may prolapse after the membranes rupture, and pressure of the presenting part on the cord could compress the cord, resulting in fetal hypoxia. The risk for hemorrhage or preeclampsia in a breech presentation is no greater than that in a cephalic presentation. Meconium in the amniotic fluid is expected because as the fetus's buttocks are compressed, meconium may be expelled.

The nurse is assessing a 12-hour-old newborn. What clinical finding should be reported to the health care provider? 1 Jaundice 2 Cephalhematoma 3 Erythema toxicum 4 Edematous genitalia

1 Jaundice occurring in the first 24 hours of life is pathological; it is associated with Rh or another blood incompatibility. Cephalhematoma is a collection of blood between the skull and periosteum that does not cross the suture line; it resolves within 6 weeks, and although it should be documented it does not require treatment. Erythema toxicum is newborn dermatitis, believed to be an inflammatory response. The rash is harmless, and although it should be documented it does not require treatment. Edematous genitalia, a response to maternal hormones, are common in newborns.

The nurse-midwife palpates the uterus of a client who is at 12 weeks' gestation and determines that it is enlarged and: 1 Just above the symphysis pubis 2 Buried deep in the pelvic cavity 3 Three fingerbreadths above the symphysis pubis 4 Causing noticeable bulging of the abdominal wall

1 At 12 weeks' gestation the enlarging uterus begins to rise out of the pelvis and is palpable just above the symphysis pubis. During the early weeks of gestation the uterus remains in the pelvic cavity. Usually this occurs at about 16 weeks' gestation. The noticeable bulging of the abdominal wall occurs later than 12 weeks' gestation when the fundus rises completely from the pelvis and enters the abdominal cavity.

A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and got a positive result. She confides that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl whether she has told anyone else, she replies, "Yes, but my mother doesn't believe me." Legally, who should the nurse notify? 1 Police concerning a possible sex crime 2 Health care provider to confirm the pregnancy 3 Child protective services for immediate intervention 4 Girl's mother about the pregnancy test's positive result

3

A nurse has inserted a nasogastric tube to gavage feed a preterm newborn. Place in order the steps the nurse will take to perform the gavage. 1. Clamp the tube. 2. Place the infant on the right side. 3. Allow the feeding to flow at a rate of 1 mL/min. 4. Connect the barrel of a syringe to the gavage tube. 5. Pour the prescribed amount of formula into the syringe.

41532 The first step is to connect the tubing to a syringe; the formula should not be poured directly into the tubing. The tube must be crimped before the formula is poured into the syringe so the flow rate may be controlled while the formula is being released from the syringe. After the tube is crimped, the formula should be poured into the syringe to ensure that the infant will receive the specified amount. Once the formula is in the syringe, the crimp is released and the rate of flow controlled. A rate of 1 mL/min is best tolerated. After the feeding has been completed, the infant should be turned on the right side to prevent aspiration. During the feeding, the infant may be held.

The mother of a newborn with exstrophy of the bladder tells the nurse that the primary health care provider said that her child may develop an unusual gait when learning to walk. What does the nurse tell the mother is the cause of waddling gait? 1 Genu varum 2 Tibial torsion 3 Subluxation of the femur 4 Separation of the pubic bone

4The incomplete fetal bladder development may interfere with development of the pelvis. Genu varum (bowlegs) may be congenital or caused by rickets; the condition is not related to exstrophy of the bladder. Tibial torsion, a rotation of the tibia, is unrelated to exstrophy of the bladder. Subluxation of the femur, a form of hip dislocation, is unrelated to exstrophy of the bladder.

What finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0° F (36.6° C) and 97.4° F (36.3° C) would be considered critical? 1 Serum calcium level of 8 mg/dL 2 Blood glucose level of 36 mg/dL 3 Respiratory rate of 60 breaths/min 4 White blood count greater than 15,000 mm3

2 Instability of the newborn's temperature is an indication of hypoglycemia. A glucose level below 40 mg/dL does not provide enough energy to maintain the body temperature at a normal level. A serum calcium level of 8 mg/dL, respiratory rate of 60 breaths/min, and a white blood cell count higher than 15,000 mm3 are all normal findings and do not affect body temperature.

After a spontaneous vaginal delivery the client expresses concern because the newborn has a red rash with small papules on the face, chest, and back. What condition does the nurse recognize? 1 Harlequin sign 2 Vernix caseosa 3 Nevus flammeus 4 Erythema toxicum

4 Erythema toxicum is a benign, generalized, transient rash that is a reaction to the new environment in which a neonate finds itself. It disappears after short time after birth. It is not the harlequin sign, which is dilation of blood vessels on one side of the body with red skin on one side, and white skin on the other. It is not vernix caseosa, which is a thick, white, greasy substance that protects the skin in utero. It is not nevus flammeus, or port wine stain, a reddish-purple capillary angioma below the dermis.

When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take? 1 Giving the infant to the mother 2 Having the visitor step outside the room 3 Verifying the infant's and mother's identification bands 4 Asking the visitor whether the coughing and sneezing are caused by a cold

2

A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, what information about the client should the nurse obtain? 1 Whether she has had a previous tuberculin test 2 Whether the client is prone to respiratory diseases 3 Whether an earlier tuberculin test's result was positive 4 Whether the client's family has a history of tuberculosis

3

A newborn is being treated with phototherapy for hyperbilirubinemia. What is the nurse's role when providing phototherapy? 1 Turning the infant every 2 hours 2 Measuring the bilirubin level every 2 hours 3 Maintaining the infant on daily 24-hour phototherapy 4 Applying a sterile gauze pad to the infant's umbilical stump

1The infant's position is changed every 2 hours to expose all skin surfaces to the phototherapy for maximum effect. The infant may be removed from the lights for feeding and the eye patches removed to assess the eyes for irritation. The lights will dry the cord more quickly, which is a desirable effect. Measuring the bilirubin level every 2 hours is not necessary.

Which behavior should a nurse identify as the Moro reflex response? 1 Extension and adduction of the arms 2 Abduction and then adduction of the arms 3 Adduction of the arms and fanning of the toes 4 Extension of the arms and curling of the fingers

2 The Moro reflex is a sudden extension and abduction of the arms at the shoulders and spreading of the fingers. This is followed by flexion and adduction of the arms with the index finger and thumb forming the letter C; the infant may cry. Extension and abduction, not adduction, is the first part of the Moro reflex. Although the reflex response includes adduction of the arms, the toes are not involved. Although the reflex starts with extension of the arms, the fingers fan out before taking the C position.

A nurse is assessing a pregnant client at the end of her second trimester. What clinical finding causes the nurse to suspect that the client has preeclampsia? 1 Progressive weight gain 2 Two samples showing proteinuria 3 Dependent ankle edema during the late afternoon 4 Blood pressure fluctuations on three successive measurements

2

A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include? 1 Changing diapers immediately when moist 2 Applying sterile, moist nonadherent dressings to the sac 3 Placing the infant in the reverse Trendelenburg position 4 Positioning the infant prone with the legs slightly adducte

2

During the physical assessment of a newborn, a nurse palpates the infant's femoral pulses. Which cardiovascular anomaly is the nurse trying to detect? 1 Atrial septal defect 2 Coarctation of the aorta 3 Patent ductus arteriosus 4 Ventricular septal defect

2

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele. What is the priority nursing intervention during the first 24 hours? 1 Using only disposable diapers for perineal care 2 Placing the infant in a prone or side-lying position 3 Washing the infant's genital area with an antiinfective 4 Performing neurologic checks above or at the site of the lesion

2 A prone or side-lying position will prevent pressure on the sac; if the sac ruptures, infection may occur. Diapers should not be applied because they may irritate or contaminate the sac. Antiinfectives are too caustic. Assessment of the area below the defect is essential to determination of motor, urinary, and bowel function.

A nurse administers two serial intramuscular injections of betamethasone (Celestone) to a woman at 32 weeks' gestation who has been admitted in preterm labor. The nurse knows that this medication is given to: 1 Stop the process of labor. 2 Increase placental perfusion. 3 Stimulate surfactant production. 4 Reduce intensity of contractions.

3 Corticosteroids stimulate surfactant production; they also have been shown to reduce the incidence of intraventricular hemorrhage. Betamethasone (Celestone) does not affect the labor process, increase placental perfusion, or affect the intensity of contractions.

The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions? 1 Relax by closing her eyes. 2 Push with her glottis open. 3 Blow to slow the birth process. 4 Pant to prevent cervical edema

2The contractions in the second stage of labor are expulsive in nature; having the client push or bear down with the glottis open will hasten expulsion. Contractions are now intense and the client will be unable to relax; relaxation occurs between contractions. Having the client close her eyes, blow, or pant will prevent pushing and should not be encouraged until the fetal head crowns (+4 station) and a controlled birth is desired.

new father tells the nurse that he is anxious about not feeling like a father. What is the priority nursing action to meet this father's needs? 1 Encouraging the father's participation in a parenting class 2 Providing time for the father to be alone with and get to know the baby 3 Offering the father a demonstration on newborn diapering, feeding, and bathing 4 Allowing time for the father to ask questions after viewing a film about a new baby

2`

A client who is at 12 weeks' gestation tells a nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. What factor is frequently associated with this disorder? 1 History of cholecystitis 2 Large amount of amniotic fluid 3 High level of chorionic gonadotropin 4 Decreased secretion of hydrochloric acid

3

After an incomplete abortion, a client tells a nurse that although her health care provider explained what an incomplete abortion was, she did not understand. What is the best response by the nurse? 1 "I don't think you should focus on this anymore." 2 "It's when the fetus dies but is retained in the uterus for at least 2 months." 3 "It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." 4 "I think it's best for you to ask your health care provider for the answer to that question."

3

In the 37th week of gestation a client with type 1 diabetes is scheduled for an amniocentesis. What should the nurse explain to the client about the purpose of this test? 1 Fetal lung maturity is determined. 2 Approximate fetal size is disclosed. 3 Placental structural defects are revealed. 4 Cephalopelvic disproportion is identified.

1

hemoglobin

12

A hysterectomy is scheduled for a client with endometrial cancer. Before the surgery, what should the nurse prepare the client to expect? 1 Nasogastric tube 2 Indwelling urinary catheter 3 Vaginal packing for 10 days 4 Jackson-Pratt drain in the abdominal incisio

2 A catheter decompresses the bladder and limits trauma to the surgical site; it eliminates the need for repeated straight catheterizations after surgery. The gastrointestinal tract does not need to be decompressed for this type of surgery. Packing is usually not necessary; if it is used after a hysterectomy, 10 days is an excessively long time. Drains usually are not necessary after a hysterectomy.

What findings occur with supine hypotensive syndrome? Select all that apply. 1 Reflex tachycardia 2 Feeling of faintness 3 Increased cardiac output 4 Increased venous pressure 5 Increased diastolic pressure 6 Decreased systolic pressure

246 Compression of the vena cava hinders venous return, which in turn results in a decrease in the systolic pressure, an increase of venous pressure in the legs, and decreased blood flow to the brain, causing the woman to feel faint. Blood pressure decreases when venous return is compromised. Supine hypotensive syndrome results in a reflex bradycardia. Cardiac output is decreased by half.

The nurse assesses a newborn, using the Apgar scale. One minute after birth the newborn has a heart rate of 120 beats/min, slow and irregular respirations, a weak cry, some flexion of extremities, and a pink body with blue extremities. What does the nurse record as the 1-minute Apgar score? 1. 4 2. 5 3. 6 4.7

3 According to the Apgar scoring scale, heart rate above 120 = 2, respirations below 30 = 1, some flexion of extremities = 1, weak cry = 1, and blue extremities = 1; these numbers total 6. Each category on the Apgar scale is assigned a 2, with 10 being the highest possible Apgar score. Scores of 4 and 5 are too low and are not accurate assessments of this newborn. A score of 7 is too high and is not an accurate assessment of this newborn.

A client has a diagnosis of an unruptured tubal pregnancy. Which assessment findings correlate with this diagnosis? Select all that apply. 1 Rigid abdomen 2 Referred shoulder pain 3 Unilateral abdominal pain 4 History of a sexually transmitted infection 5 Ecchymotic blueness around the umbilicus

34 Pain usually occurs at the location of the affected tube before it has ruptured. STIs are related to pelvic inflammatory disease; the finding that the client has had an STI increases the likelihood that the tubes will be affected, resulting in a tubal pregnancy. A rigid abdomen is not expected if the tube has not ruptured; this finding occurs after the rupture of a tubal pregnancy. Referred shoulder pain occurs as a result of diaphragmatic irritation caused by blood in the peritoneal cavity after a tubal pregnancy ruptures, not before rupture. Ecchymotic blueness around the umbilicus (the Cullen sign) indicates hematoperitoneum in a ruptured intra-abdominal ectopic pregnancy.

A priority intervention for the infant undergoing phototherapy is: 1 Covering the infant's face with a soft mask 2 Administering glucose water between breast or bottle feedings 3 Keeping the infant in the supine position with the genitals covered 4 Exposing as much skin as possible by turning the infant every 2 hours

4

Right occipitoanterior ROA

small part on left smooth back on right hard round head in pubic

Left occipitoanterior

small parts (fingers) on right smooth back on left hard firm head in pelvis/pubic

fter a newborn has skin-to-skin contact with the mother, a nurse places the newborn under a radiant warmer. What complication is the nurse attempting to prevent? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1 Uncorrected cold stress increases anaerobic glycolysis, which increases acid production, resulting in metabolic acidosis. Metabolic acidosis, not metabolic alkalosis, occurs when a neonate is stressed by cold. Cold stress causes a metabolic, not a respiratory, problem; metabolic acidosis, not respiratory acidosis, occurs. Cold stress causes a metabolic, not a respiratory, problem; metabolic acidosis, not respiratory alkalosis, occurs.

A couple is concerned about the risks associated with an in vitro fertilization embryo transfer (IVF-ET).Which of the following is a risk factor associated with IVF? 1 Embryonic HIV 2 Tubal pregnancy 3 Congenital anomalies 4 Hyperemesis gravidarum

2

What should the nurse do to enhance a neonate's behavioral development? 1 Keep the infant awake for longer periods of time before each feeding. 2 Touch and talk to the infant hourly, starting at least 3 hours after birth. 3 Encourage parental contact with the baby for 15-minutes every 4 hours. 4 Help the parents stimulate their awake baby through touch, sound, and sight.

4

A nurse is trying to determine whether a pregnant woman's membranes have ruptured. What findings support the conclusion that they have ruptured? Select all that apply. 1 The expelled fluid totals 500 mL. 2 The expelled fluid is light yellow. 3 The expelled fluid smells similar to urine. 4 Nitrazine paper turns blue on contact with the fluid. 5 Microscopic examination of the fluid reveals ferning.

45 An alkaline fluid will turn Nitrazine paper blue; amniotic fluid is alkaline. Amniotic fluid demonstrates a ferning pattern, is visible with a microscope, when placed on a slide. It is not the amount of fluid that is observed but the characteristics of the fluid that are significant. Amniotic fluid should be clear and may contain white specks of vernix. Yellow coloration indicates that the fluid may be urine. Green fluid is indicative of meconium staining, which is a nonreassuring fetal sign. The odor of amniotic fluid is not similar to that of urine. Amniotic fluid has a mild, somewhat fleshy odor.

A client has a first-trimester aspiration abortion. Which statement indicates to the nurse that the client understands the discharge instructions? 1 "We can start having sex again in 4 or 5 days." 2 "My period should start again in 2 or 3 weeks." 3 "I can use tampons instead of pads after 24 hours." 4 "I'll call you if I have to change my pad more than once in 4 hours.

4Needing to change a sanitary pad more than once in 4 hours indicates that the bleeding is excessive and that the health care provider should be notified. Although instructions vary among providers, sexual intercourse may usually be resumed in 1 to 3 weeks. The menstrual period usually resumes in 4 to 6 weeks. Although instructions vary among health care providers, tampons should be avoided for 3 days to 3 weeks.

What is the priority nursing intervention for a client who has just given birth to her fifth child? 1 Palpating her fundus frequently because she is at risk for uterine atony 2 Offering her fluids because multiparas generally lose more fluid during labor 3 Assessing her bladder tone because she is at increased risk for urinary tract infection 4 Performing passive range-of-motion exercises on her extremities because she is at risk for thrombophlebitis

1 Because of the client's multiparity, postpartum uterine involution may be ineffective. Primiparas, not multiparas, become more dehydrated because their labors are usually longer. There is no evidence of increased risk for a urinary tract infection, but routine assessment of bladder tone should be performed. Clients are encouraged to ambulate soon after birth; it is too soon to be concerned about the effects of immobility.

At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What does the nurse do first in response? 1 Stimulates crying 2 Substitutes sterile water for the formula 3 Suctions and then oxygenates the newborn 4 Stops the feeding momentarily and then restarts it

3 Cyanosis, choking, and coughing are signs of aspiration and hypoxia. Suctioning and oxygenation are needed. Crying may add to the distress. Water could be aspirated, worsening the problem. Stopping the feeding momentarily and then restarting it is unsafe; the newborn is showing signs of a blocked airway.

A client is admitted in active labor at 39 weeks' gestation. During the initial examination the nurse identifies multiple red blister-like lesions on the edges of the client's vaginal orifice. Once the nurse has spoken to the practitioner and receive prescriptions, the priority nursing action is: 1 Beginning the IV antibiotic 2 Preparing for a cesarean birth 3 Taking a smear of the lesions for testing 4 Documenting the need for double gloving

2 probably herpes infection

A nurse is assessing a newborn. What finding indicates the need for follow-up care? 1 Presence of the Babinski reflex 2 A head circumference of 33 cm 3 30-degree abduction of the infant's hips 4 An umbilical cord containing three vessel

3 Thirty degrees represents limited hip abduction and is indicative of developmental dysplasia of the hip. The Babinski reflex is an expected newborn finding. A head circumference of 33 cm is an expected measurement for a newborn at term. An umbilical cord with three vessels is an expected finding.

What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? 1 Document the fetal heart rate every 5 minutes. 2 Call the anesthesia department to alert the staff there of an imminent birth. 3 Assist the client's coach in helping her with the use of breathing techniques. 4 Suggest that the client accept the PRN medication for pain that has been prescribed.

3

By how much should the nurse instruct a pregnant client to increase her daily protein intake? 1 10 g 2 20 g 3 30 g 4 40 g

1Ten grams is the amount of increase in the daily protein intake recommended for pregnant women by the Food and Nutrition Board of the National Academy of Sciences. Twenty, 30, and 40 g are all more than the recommended amount, although most women in developed countries exceed the requirement.

A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse notes blood oozing from the penis. Which intervention should the nurse implement? 1 Cleansing the area with warm water and mild soap 2 Applying Vaseline gauze over the area of bleeding 3 Documenting the amount of bleeding in the infant's chart 4 Donning sterile gloves and applying direct pressure, using sterile gauze

4

A mother who is formula feeding her 1-month-old infant asks the nurse whether any vitamin or mineral supplements are required. The nurse bases the reply on the knowledge that infants who are fed with ready-to-use formula do require a supplement. What supplement is required? 1 Iron 2 Fluoride 3 Vitamin K 4 Vitamin B12

2 Unless fluoridated water is used by the manufacturer, fluoride supplementation of 0.25 mg daily is required. Commercial formulas are fortified with iron. The supply of vitamin K is adequate after the first week of life. Supplemental vitamin B12 is unnecessary; it may be needed if the mother is a vegetarian and is breastfeeding.

While assessing a newborn the nurse notes the following findings: arms and legs slightly flexed; smooth, transparent skin; abundant lanugo on the back; slow recoil of the pinnae; and few sole creases. What complication does the nurse anticipate in light of these findings? 1 Polycythemia 2 Hyperglycemia 3 Postmaturity syndrome 4 Respiratory distress syndrome

4The assessment findings are indicative of a preterm infant; therefore the nurse should monitor the infant for signs of respiratory distress syndrome. Polycythemia may develop in a preterm large-for-gestational-age (LGA) infant, but there are no data to indicate that the infant is LGA. Preterm infants may become hypoglycemic, not hyperglycemic. The neonate is preterm, not postterm.

A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response in language the client will understand? 1 Respirations are enhanced. 2 Bladder tonicity is increased. 3 Abdominal muscles are strengthened. 4 Peripheral vasomotor activity is promoted

4There is extensive activation of the blood clotting factors after a birth; this, together with immobility, trauma, or sepsis, encourages thromboembolization, which can be limited through activity. Respirations are enhanced by encouraging the client to turn from side to side and to deep-breathe and cough. Bladder tone is improved by the regular emptying and filling of the bladder. Exercise during the next 6 weeks can strengthen the abdominal muscles.

A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented? 1 Precipitous vaginal delivery 2 Prolonged transitional phase 3 Primigravida primary delivery 4 Normal spontaneous vaginal delivery

1 A delivery that takes less than 3 hours is considered precipitous. A multipara usually progresses at the rate of 1.5 cm of dilation per hour and must progress to 10 cm for delivery. The second stage, birth, usually averages approximately 20 minutes. Although this was a vaginal delivery, it was faster than average. A prolonged transitional phase would indicate that progression from 8 to 10 cm took longer than expected and would require augmentation. Primigravida means "first pregnancy," so this cannot be not possible if the client is multiparous, having delivered before.

For what complication should the nurse specifically monitor a grand multipara who has just given birth? 1 Uterine atony 2 Bladder distention 3 Profuse diaphoresis 4 Hypertensive episodes

1 Grand multiparas have diminished uterine muscle tone as a result of the repeated distentions of pregnancy; consequently, the uterine muscles may not contract effectively during the fourth stage of labor. Bladder distention may occur in any postpartum clients; it is not specific to grand multiparas. Profuse sweating occurs in all postpartum clients; it is the body's attempt to excrete excess fluid accumulated during pregnancy. Hypertensive episodes may be indicative of chronic hypertension, which is not specific to grand multiparas.

A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond? 1 "During the eighth week of the pregnancy." 2 "At the end of the second week of pregnancy." 3 "When the fertilized egg becomes implanted." 4 "When the products of conception are seen on the sonogram

1During the eighth week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth. At the end of the second week of pregnancy, the developing cells are called an embryo. At the time of implantation, the group of developing cells is called a blastocyst. The embryo can be visualized on ultrasound before it becomes a fetus.

The nurse is assigned to care for an infant in the newborn nursery who is 24 hours old. During assessment the nurse becomes concerned that the baby is jaundiced. The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches: 1 1 to 3 mg/dL 2 2 to 4 mg/dL 3 5 to 7 mg/dL 4 8 to 10 mg/dL

3

One minute after birth a newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What is the first Apgar score?

3 A heart rate less than 100 beats/min receives a score of 1; slow, irregular respirations score 1; grimacing in response to suctioning scores 1; flaccid muscle tone scores 0; and cyanosis scores 0, for a total score of 3.

A nurse is teaching a young primigravida about body changes during pregnancy. The nurse explains that most prenatal clients experience urinary frequency in the first trimester because of an increase in: 1 Estrogen level 2 Extracellular fluid volume 3 Kidney glomerular filtration 4 Bladder pressure from the enlarged uterus

4

A nurse on the postpartum unit is providing postpartum care instructions to a 21-year-old Hispanic woman who delivered her first baby yesterday without complications. Her husband, mother, and other family members have been with her since delivery. The mother speaks and understands very little English, but her husband and sister speak some English. What is the best way to ensure that the client and her family understand what is being said? 1 Providing the teaching to all family members and the client 2 Asking the client and her family to nod their heads to verify understanding 3 Asking the client and her family members to say yes to verify understanding 4 Asking the client and family members to repeat, in their own words, what they have been told

4

A preterm infant is started on digoxin (Lanoxin) and furosemide (Lasix) for persistent patent ductus arteriosus. Which nursing assessment provides the best indication of the effectiveness of the furosemide? 1 Pedal edema is reduced. 2 Digoxin toxicity is avoided. 3 Fontanels appear depressed. 4 Urine output exceeds fluid intak

4

An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the position of the fetus is: 1 Breech 2 Transverse 3 Occiput anterior 4 Occiput posterior

4 A persistent occiput posterior position causes intense back pain because of fetal compression of the maternal sacral nerves. The breech position is not associated with back pain. The transverse position does not usually cause back pain. Occiput anterior is the most common fetal position and does not cause back pain.

A client at 37 weeks' gestation is in active labor. Her contractions are now 2 to 3 minutes apart and lasting approximately 60 seconds. The fetal heart rate (FHR) averages around 100 beats/min between contractions. What should the nurse do next? 1 Notify the primary health care provider. 2 Monitor the fetal heart rate continuously. 3 Check the client's perineum for a prolapsed cord. 4 Document the findings in the client's medical record.

1 Bradycardia of 100 beats/min may be a benign finding caused by a vagal response to prolonged head compression or a sign of progressive fetal hypoxia and acidosis. The primary care provider should be notified of the baseline FHR and variability. Monitoring should be continued to determine the cause of the bradycardia, and then the nurse should act accordingly. Although monitoring should be continuous, the practitioner should be informed of the bradycardia. There is no evidence that the client's membranes have ruptured, necessitating this observation. The expected fetal heart rate between contractions is 110 to 160 beats/min; simply documenting the findings is inadequate.

A primigravida at 38 weeks of gestation presents to the clinic with a blood pressure of 142/94, edema in all extremities, and a weight gain of five pounds since the previous checkup one week ago. During the assessment, symptoms suggestive of preeclampsia were obtained. Select all that apply. 1 Headache 2 Double vision 3 Brisk reflexes 4 Epigastric pain 5 Sluggish reflexes 6 Edema of +1 in lower extremities

1234 A severe headache occurs with cerebral edema, double vision occurs because of retinal edema, reflexes are brisk because of central nervous system changes, and epigastric pain accompanies hepatic edema. Sluggish reflexes would not accompany preeclampsia. Edema of +1 is minimal and is present in many pregnant women in the lower extremities. Edema above the waist is considered significant.

A nurse is discussing diet with a pregnant client who is 5 feet 4 inches tall and whose prepregnancy weight was 120 lb. What should the nurse include about the changes in calories and nutrients, compared with the prepregnancy diet, during the second trimester? 1 Decreasing daily fat consumption by 220 calories 2 Increasing total daily caloric intake by 340 calories 3 Increasing total daily caloric intake by 460 calories 4 Decreasing daily carbohydrate consumption by 130 calories

2 A daily increase of 340 calories is recommended for adult women during the second trimester of pregnancy. Decreasing fat or carbohydrates in the diet will result in weight reduction, which is not recommended during pregnancy. A daily increase of 462 calories is recommended for adult women during the third trimester of pregnancy.

nurse is teaching a class of expectant parents about nutritional needs during pregnancy. What information should the nurse include? 1 Carbohydrate needs decrease during pregnancy. 2 Protein needs increase to at least 70 g/day during pregnancy. 3 Phosphorus and calcium needs decrease gradually throughout pregnancy. 4 Caloric needs increase gradually up to 100 more kcal/day throughout pregnancy.

2 An increase in all nutrients is needed to meet the increased metabolic requirements of pregnancy. Increased amounts of protein are needed for growth and maintenance of maternal and fetal tissues. Calcium and phosphorus needs increase to meet the rapid demand for fetal bone deposits during the last month of pregnancy. Caloric needs increase by a minimum of 300 kcal/day during pregnancy.

While conducting prenatal teaching, a nurse should explain to clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. What causes this increase? 1 Decreased metabolic rate 2 Increased production of estrogen 3 Secretion from the Bartholin glands 4 Supply of sodium chloride to the vaginal cells

2 Increased estrogen production during pregnancy causes hyperplasia of the vaginal mucosa, which leads to increased production of mucus by the endocervical glands. The mucus contains exfoliated epithelial cells. Increased metabolism leads to systemic changes but does not increase vaginal discharge. The amount of secretion from the Bartholin glands, which lubricates the vagina during intercourse, remains unchanged during pregnancy. There is no additional supply of sodium chloride to the vaginal cells during pregnancy.

A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her hemoglobin level is 10.6 g/dL and her hematocrit is 31%. What does the nurse identify as the reason for these hemoglobin and hematocrit levels? 1 Infection 2 Hemodilution 3 Nutritional deficits 4 Concealed bleeding

2 Infection does not lead to a lower hematocrit. The increase in circulating blood volume during pregnancy is reflected in lower hemoglobin and hematocrit readings (physiological anemia of pregnancy). The history reveals no prenatal problems, and weight gain is adequate. In the absence of other significant signs and symptoms, concealed bleeding is unlikely.

A nurse is counseling a woman who has just been found to have a multiple gestation. Why does the nurse consider this pregnancy high risk? 1 Postpartum hemorrhage is an expected complication. 2 Perinatal mortality is two to three times more likely in multiple than in single births. 3 Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. 4 Maternal mortality is higher during the prenatal period in the setting of multiple gestation.

2 Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.

A nurse is caring for a client who is having a prolonged labor. The client is annoyed and very concerned because her labor is deviating from what she perceives as normal. After the nurse has acknowledged the client's feelings, what is the best next intervention? 1 "I'll leave so you can talk to your partner." 2 "I'll rub your back, and you tell me if it helps." 3 "Let's talk some more about what's really bothering you." 4 "Women usually become weary and frustrated during labor."

2 Rubbing the client's back and asking the client to report whether it helps offers comfort measures while giving the client an opportunity to verbalize her concerns further if she desires. Offering to leave so that the client may talk to her partner cuts off communication with the client. The client's focus is on her prolonged discomfort; there is no indication that she has other concerns at this time. The nurse should focus on the client, not on how other women may feel; this response may cut off communication.

A client with heart disease is admitted to the birthing suite. How can the nurse try to prevent the development of cardiac decompensation during her labor? 1 Positioning her on the side with her head on a pillow 2 Positioning her on the side with her shoulders elevated 3 Administering the prescribed intravenous infusion of isotonic saline 4 Administering the prescribed intravenous piggyback infusion of oxytocin

22 The side-lying position, particularly the left, takes the weight off large blood vessels, increasing blood flow to the heart; elevating the shoulders relieves pressure on the diaphragm. The client's head is too low in this position if she is only positioned with her head on a pillow; it should be elevated above the shoulders. Sodium leads to increased fluid retention; it is contraindicated in a client with heart disease; if it is prescribed, the nurse should question the health care provider. Administering the prescribed intravenous piggyback infusion of oxytocin is contraindicated unless some uterine inertia occurs; if it is prescribed, the nurse should question the health care provider.

A nurse is planning a prenatal class about the changes that occur during pregnancy and the necessity of routine health care throughout pregnancy. Which cardiovascular compensatory mechanisms should the nurse explain will occur? Select all that apply. 1 Systemic vasodilation 2 Increased blood volume 3 Increased blood pressure 4 Increased cardiac output 5 Enlargement of the heart 6 Decreased erythrocyte production

245 Blood volume increases to meet the metabolic demands of pregnancy. Increased cardiac output is necessary to accommodate the increased blood volume needed to meet the demands of the growing fetus. Cardiac hypertrophy is a result of the demands made by the increased blood volume and cardiac output. Systemic vasodilation is not expected. There is little variation in blood pressure but a slight decrease during the second trimester. Erythrocyte production increases; because the plasma volume increases more than the red blood cell count, the hematocrit is lower.

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer? 1 Clopidogrel (Plavix) 2 Warfarin (Coumadin) 3 Continuous infusion of heparin 4 Intermittent doses of a low-molecular-weight heparin

3 Heparin is the medication of choice during the acute phase of a deep vein thrombosis; it prevents conversion of fibrinogen to fibrin and of prothrombin to thrombin. Clopidogrel (Plavix) is a platelet aggregate inhibitor and is used to reduce the risk of a brain attack. Warfarin (Coumadin), a long-acting oral anticoagulant, is started after the acute stage has subsided; it is continued for 2 to 3 months. A low molecular weight heparin (e.g., enoxaparin [Lovenox]) is not administered during the acute stage; it may be administered later to prevent future deep vein thromboses

A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear? 1 Maternity girdle 2 Support stockings 3 Low-heeled shoes 4 Loose-fitting clothing

3 Low-heeled supportive shoes help maintain the body's center of gravity over the hips, limiting arching of the back that compensates for the increased weight in the abdominal area. Maternity girdles are no longer recommended. Support stockings may be helpful for a woman with varicose veins or ankle edema, but wearing them does not prevent back pain. Loose-fitting clothing may be comfortable but does not prevent back pain.

A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client? 1 Fewer contractions 2 Depressed respirations 3 Decreased blood pressure 4 Accumulated respiratory secretions

3 Mild reactions, including vertigo, dizziness, and hypotension, occur because of vasodilation resulting from direct action of these medications on the mother's pelvic blood vessels. The progress of labor is not affected by a local anesthetic administered during the second stage of labor. A local anesthetic does not affect the respiratory center in the central nervous system. Accumulated respiratory secretions are not caused by a local anesthetic administered during the second stage of labor.

A 36-year-old woman comes to the emergency department complaining of severe abdominal cramping and heavy bleeding. She informs the nurse that she is 10 weeks pregnant. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of miscarriage is the client experiencing? 1 Missed 2 Complete 3 Inevitable 4 Threatened

3 Miscarriage is inevitable because the cervical os has opened, heavy bleeding is occurring, and tissue is present with the bleeding. In a missed miscarriage, the fetus has died but the products of conception are retained in utero for as long as several weeks. There may be no bleeding or cramping, and the os is closed. In a complete miscarriage all fetal tissue has already passed and the cervix is closed; there may be slight bleeding. Symptoms of a threatened miscarriage include spotting and a closed cervical os. There may be mild cramping.

A client tells a nurse in the prenatal clinic that she has vaginal staining but no pain. Her history reveals amenorrhea for the last 2 months and pregnancy confirmation after her first missed period. What type of abortion is suspected? 1 Missed 2 Inevitable 3 Threatened 4 Incomplete

3 Spotting in the first trimester may indicate that the client is having a threatened abortion; any client with the possibility of hemorrhage should not be left alone, so her admission to the hospital helps ensure her safety. A missed abortion may not cause any outward signs or symptoms, except that the signs of pregnancy disappear. An inevitable abortion can be confirmed only if vaginal examination reveals cervical dilation. With an incomplete abortion some, but not all, of the products of conception have been expelled.

A pregnant woman reports nausea and vomiting during the first trimester of pregnancy. The nurse explains that an increase in which hormone is the precipitating cause of the nausea and vomiting? 1 Estrogen 2 Progesterone 3 Luteinizing hormone 4 Chorionic gonadotropin

4 Chorionic gonadotropin, secreted in large amounts by the placenta during gestation, and the metabolic changes associated with pregnancy can precipitate nausea and vomiting in early pregnancy; usually the manifestations of morning sickness disappear after the first trimester. Estrogen and progesterone are increased throughout pregnancy, but neither is the cause of the nausea and vomiting. Luteinizing hormone is present only during ovulation.

What should the plan of care for a client with a tentative diagnosis of partial abruptio placentae include? 1 Bedrest with sedation 2 Trendelenburg position and hydration 3 Preparation for emergency cesarean birth 4 External fetal monitoring and oxygenation

4 Fetal monitoring and oxygen administration should be instituted to protect the fetus, because some placental separation has occurred and it may progress further. Sedation is contraindicated; it may further stress an already compromised fetus. The Trendelenburg position may shift the heavy uterus against the diaphragm and lead to compromised maternal respiratory function, further depriving the fetus of oxygen. Hydration is not a priority at this time. Further assessment of fetal status and progression of abruptio is needed before a cesarean birth is considered.

A client in active labor arrives in the birthing unit, and birth is imminent. What is the most important question for the nurse to ask at this time? 1 "Is this your first baby?" 2 "Have your membranes ruptured?" 3 "When did your contractions begin?" 4 "When is your baby's expected date of birth?

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

A client whose weight was average for her height before becoming pregnant is concerned because she has gained 15 lb (6.9 kg) after only 23 weeks of pregnancy. What is the nurse's most appropriate response? 1 "You have not gained enough weight. Can you increase your daily intake of calories?" 2 "Your weight is not a concern. I'll refer you to the dietitian, who will review your diet." 3 "You've gained too much weight for 23 weeks' gestation. Are your rings getting tight?" 4 "Your weight is expected for someone at 23 weeks' gestation. Continue the pregnancy diet."

4 The recommended average weight gain is 2.2 to 5.5 lb (1 to 2.5 kg) during the first 12 weeks, then approximately 1 lb (0.45 kg) per week until birth; 14 to 16 lb (6.4 to 7.3 kg) is an appropriate weight gain at 23 weeks' gestation. Stating that the client has not gained enough weight is inaccurate information. The nurse has dismissed the client's concern; also, the nurse is abdicating the responsibility for teaching by the referral to the dietitian. Stating that the client has gained too much weight for 23 weeks' gestation is inaccurate information that may produce anxiety. It implies that the client may have preeclampsia.

using the five-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks. 1 G4, T2, P1, A1, L2 2 G4, T1, P2, A1, L1 3 G4, T1, P1, A1, L3 4 G4, T2, P1, A1, L1

3

A nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. What is the priority nursing action? 1 Limiting caloric intake to decrease metabolic rate 2 Maintaining the prone position to prevent aspiration 3 Limiting oxygen concentration to prevent eye damage 4 Maintaining a high-humidity environment to promote gas exchang

4

A client in labor is being prepared for a cesarean birth. What is the most important nursing intervention before anesthesia is administered? 1 Preparing the abdomen 2 Obtaining informed consent 3 Initiating an intravenous infusion 4 Inserting an indwelling urinary cathet

2

A nurse is caring for a 3-week-old infant who was admitted with untreated phenylketonuria (PKU). How should the nurse document the odor of the infant's urine? 1 Fishy 2 Ammoniacal 3 Mousy or musty 4 Aromatic or pungent

3

Twelve hours after delivery the nurse is checking the client. Where does the nurse expect to find the fundus once the woman has voided?

midline, slightly above umblicus

Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. The nurse should immediately: 1 Reposition the client from supine to left lateral. 2 Increase the intravenous flow rate from 125 to 150 mL/hr. 3 Administer oxygen at a rate of 8 to 10 L/min by way of facemask. 4 Assess the maternal blood pressure for a systolic pressure below 100 mm Hg.

1

A woman who is pregnant for the first time is concerned about regaining her figure after her baby is born and wishes to diet during pregnancy. What should the nurse advise her? 1 Inadequate food intake can result in a low-birth-weight infant. 2 Dieting is recommended to lessen the incidence of stillbirth. 3 Dieting is recommended to make the birthing process easier. 4 Inadequate food intake can cause gestational diabetes mellitus.

1

hich breathing technique should the nurse instruct the client to use as the head of the fetus is crowning? 1 Shallow 2 Blowing 3 Slow chest 4 Modified paced

2

One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry; moves all extremities well; and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score? 1 9 2 8 3 7 4 6

2

A client with poorly controlled type 1 diabetes is now in her 34th week of pregnancy. The practitioner tells her that she should have an amniocentesis at 37 weeks to assess fetal lung maturity and that induction of labor will be initiated if the fetus's lungs are mature. The client asks the nurse why an early birth may be necessary. How should the nurse reply? 1 "You'll be protected from developing hypertension." 2 "Your glucose level will be hard to control as you reach term." 3 "The baby will be small enough for you to have a vaginal birth." 4 "The chance that your baby will have hypoglycemia will be reduced."

2 The reason that risk to the fetus increases as the pregnancy reaches term secondary to the mother's poorly controlled diabetes provides accurate information and answers the client's direct question. Labor is never induced for the sole purpose of preventing preeclampsia. This is not the reason for early induction; the longer the pregnancy is allowed to progress, the greater the risk for complications or a stillbirth; if the fetus becomes compromised, an emergency cesarean birth is usually required. Neonates can develop hypoglycemia shortly after birth related to many factors such as gestational diabetes and hypothermia, but this is not related to an early birth. The infant's size is anticipated to be larger than normal, not smaller.

During her first visit to the prenatal clinic a client is found to be obese. During the ensuing 5 months, the client has not been successful adhering to her nutritional plan. Which finding indicates to the nurse that the client has been successful during the sixth month? 1 Weight loss of 1 lb 2 Weight gain of 2 lb 3 No change in weight from last month 4 The client's statement that she lost weight last week

2 although obese, need to gain weight

A nurse on the postpartum unit is assessing several clients. Which clinical finding requires immediate investigation? 1 An inflamed episiotomy 2 A slow trickle of blood from the vagina 3 An estimated blood loss of half a liter during a vaginal birth 4 A boggy uterine fundus that becomes firm after prolonged massage

22 Vaginal bleeding may be an early sign of hemorrhage; hypovolemic shock can develop. An inflamed episiotomy is an expected finding; ice packs help resolve the inflammation. Expected blood loss for a vaginal birth is 300 to 500 mL. A fundus that has been overstretched or is multiparous may require prolonged massage until it becomes firm.

A client at 10 weeks' gestation complains of frequent urination. Before explaining this phenomenon to the client in language that she will understand, the nurse remembers that: 1 Glomerular filtration rate and renal plasma flow increase early in pregnancy. 2 The walls of the ureters undergo muscle tone relaxation during the first trimester. 3 Softening and compressibility of the lower uterine segment results in uterine anteflexion. 4 The uterus is taking on a globular shape as the uterine walls strengthen and become elastic.

3 Uterine anteflexion allows the uterine fundus to press on the urinary bladder, causing urinary frequency. Increased glomerular filtration rate and renal plasma flow changes do not produce urinary frequency; nor does muscle tone relaxation. The uterus does not become globular until the second trimester.

nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. For what complication associated with this problem should the nurse monitor this client? 1 Brain attack 2 Pulmonary edema 3 Impending seizures 4 Hypovolemic shock

4 uterine bleeding can result in hemorrhage-hypovolemic shock

A client at 28 weeks' gestation has a sonogram. The results reveal a small-for-gestational age fetus and a low-lying placenta. For what complication should the nurse assess this client during the last trimester of pregnancy? 1 Preterm labor 2 Placenta previa 3 Premature separation of the placenta 4 Premature rupture of the membranes2

Placenta previa is defined as an abnormally implanted placenta in the thin lower-uterine segment (i.e., low-lying, partially covering, or completely covering the cervical os). Preterm labor may occur at any time; it is not specific to a low-lying placenta. Premature separation of the placenta may occur with a normally implanted placenta. Premature rupture of the membranes may occur at any time, with or without a low-lying placenta.

Organize the steps in infant cardiopulmonary resuscitation (CPR) in the correct sequence. 1. Check the pulse at the brachial artery. 2. Initiate chest compressions in a 30:2 ratio. 3. Position the infant supine on a firm, flat surface. 4. Initiate rescue breathing at a rate of 40 to 60 breaths/min. 5. Note the infant's color and tap or gently shake the shoulders. 6. Open the airway with the head tilt-chin lift method and listen for exhalation

The steps in infant CPR are assess responsiveness, position the infant, open the airway, assess breathing, initiate breathing, assess circulation, initiate compressions.

During a prenatal examination a nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for: 1 Acute hemolytic anemia 2 Respiratory distress syndrome 3 Protein metabolism deficiency 4 Physiologic hyperbilirubinemia

a

What characteristic does the nurse anticipate in an infant born at 32 weeks' gestation? 1 Barely visible areolae and nipples 2 Ear pinnae that spring back when folded 3 Definite creases of the infant's palms and soles 4 A zero-degree angle on the square window sign

1 Breast tissue is not palpable in a newborn of less than 33 weeks' gestation. The ear pinnae spring back in an infant at 36 weeks' gestation. Creases of the palms and soles are not clearly defined until after the 37th week of gestation. A zero-degree square window sign is present in an infant at 40 to 42 weeks' gestation.

A client with mild preeclampsia is admitted to the high-risk prenatal unit because her blood pressure is progressively increasing. The nurse reviews the practitioner's prescriptions. What prescriptions does the nurse expect? Select all that apply. 1 Daily weight 2 Side-lying bed rest 3 2-gram-sodium diet 4 Deep tendon reflexes 5 Glucose tolerance test

124

On her first visit to the prenatal clinic a client with rheumatic heart disease asks the nurse whether she has special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? Select all that apply. 1 Iron 2 Calcium 3 Folic acid 4 Vitamin C 5 Vitamin B12

13 Because pregnant women with heart disease are more likely to have anemia, there may be an additional need for iron and also for folic acid. If the pregnant client with heart disease is eating the recommended pregnancy diet and taking prenatal vitamin and mineral supplements, there is no additional need for calcium, vitamin C, and vitamin B12.

A nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight? 1 Placing the naked infant on the scale 2 Removing the infant's clothes except for the diaper before weighing 3 Weighing the infant's clothes and then subtracting that weight from the clothed infant's weight 4 Having the mother hold the infant while on an adult scale and subtracting the mother's weight from the combined weight

1

A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone (Celestone) 12 mg is prescribed. What should the nurse tell the client about why the medication is being given? 1 Cervical dilation is increased. 2 Fetal lung maturity is accelerated. 3 The risk of a precipitous birth is reduced. 4 The potential for maternal hypertension is minimized

2

A client admitted to the high-risk unit with a threatened abortion anxiously asks the nurse, "Could this have happened because I had the flu?" How should the nurse respond? 1 "Tell me why you feel this way. Do you think that you did something to cause the bleeding?" 2 "We know that maternal infection sometimes results in miscarriage. Perhaps the flu did cause it." 3 "I'm sure that there's nothing you could have done to cause this. You shouldn't worry about it." 4 "The doctor will be here soon and will be better prepared to answer your questions. Why don't you wait until then?"

1

lient in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate? 1 Cesarean birth 2 Prolonged labor 3 Rapidly induced labor 4 Vacuum extraction vaginal birt

1Immediate birth is necessary to prevent fetal hypoxia and death. The other options will increase pressure on the cord, resulting in fetal hypoxia.

A client at 36 weeks' gestation exhibits oligohydramnios. What newborn complication should the nurse anticipate? 1 Spina bifida 2 Imperforate anus 3 Tracheoesophageal fistula 4 Intrauterine growth restriction (IUGR)

4

A nurse is assessing a woman with a probable ruptured tubal pregnancy. What clinical manifestation requires immediate intervention? 1 Abdominal distention 2 Intermittent abdominal contractions 3 Dull, continuous upper-quadrant abdominal pain 4 Sudden onset of knifelike pain in one of the lower quadrants

44 One symptom of sudden rupture of a fallopian tube is pain on the affected side, usually sudden, excruciating, and radiating over the lower abdomen and to the shoulder; sometimes the pain is associated with nausea, vomiting, and diarrhea. Abdominal distention is not a classic sign of a ruptured fallopian tube. There are no contractions because the pregnancy is not uterine. The pain is exquisite, sharp (not dull) and sudden in the lower abdomen when the fallopian tube ruptures.

A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? Select all that apply. 1 Yogurt 2 Oily fish 3 Apricots 4 Raw shellfish 5 Herbal supplements 6 Soft-scrambled eggs

456 The March of Dimes has included raw shellfish, which may be contaminated with hepatitis or typhoid, on its list of foods to avoid during pregnancy. Herbal supplements and teas often contain ingredients that are medicinal and should not be taken during pregnancy unless a health care provider has been consulted regarding their safety. The March of Dimes has included soft-scrambled eggs on its list of foods to avoid during pregnancy because they may be contaminated with Salmonella. Yogurt is an excellent source of calcium and is safe to eat during pregnancy. Oily fish has a high level of omega-3 oils and is safe to eat in limited amounts during pregnancy. Apricots are a source of potassium and are safe to eat during pregnancy.

A client with severe preeclampsia is hospitalized. What should a nurse do first to ensure her physical safety? 1 Institute seizure precautions. 2 Decrease environmental stimuli. 3 Administer the prescribed sedatives. 4 Strictly monitor her intake and output.

1

A client's membranes rupture while her labor is being augmented with an oxytocin (Pitocin) infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next? 1 Changing the client's position 2 Taking the client's blood pressure 3 Stopping the client's oxytocin infusion 4 Preparing the client for an immediate birt

1

A nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when during contractions the fetal heart rate shows: 1 Late decelerations 2 Early accelerations 3 Variable decelerations 4 Prolonged accelerations

1

A nurse is caring for a client who has had a spontaneous abortion. For what complication should the nurse assess this client? 1 Hemorrhage 2 Dehydration 3 Hypertension 4 Subinvolution

1

A nurse who is assessing a newborn 1 minute after birth determines that the cry is lusty, the heart rate is 150 beats/min, and the extremities are flexed but that the bottoms of the feet have a marked bluish tinge. What Apgar score does the nurse assign to the neonate?

9

A client with a diagnosis of severe preeclampsia is admitted to the hospital from the emergency department. What precaution should the nurse initiate? 1 Padding the side rails on the bed 2 Placing the call button next to the client 3 Having oxygen and a facemask available 4 Assigning a nursing assistant to stay with the client

1

A new mother asks a nurse why medicine is being put in her baby's eyes. What infection should the nurse tell the mother it is given to prevent? 1 Chlamydia 2 Candidiasis 3 Streptococcus 4 Staphylococcus

1 Chlamydial infection can cause conjunctivitis in a neonate; prophylactic antibiotic ointment can prevent this infection. Candidiasis can cause mycotic stomatitis (thrush) in a neonate. Streptococcus infection can cause septicemia in a neonate. Staphlyococcus infection can cause skin infection in a neonate.

An infant was born 30 minutes ago. The nurse is preparing an injection of vitamin K for the infant. Which dosage and route will the nurse use? 1 1.0 to 1.5 mg given intramuscularly 2 0.5 to 1.0 mg given intramuscularly 3 1.0 to 1.5 mg given subcutaneously 4 0.5 to 1.0 mg given subcutaneously

2

A client in labor, dilated 4 cm, is admitted to the birthing room. An electronic fetal monitor is applied. Which assessment should alert the nurse of the need to notify the practitioner? 1 Contractions every 4 minutes that last 50 seconds 2 Contractions every minute that last for 120 seconds 3 Fetal heart rate accelerations at the beginning of a contraction 4 Fetal heart rate decelerations to 110 beats/min before the peak of a contraction

2 These contractions are too frequent and prolonged for a client who is dilated only 4 cm; she may become exhausted, which will compromise the fetus. Contractions every 4 minutes that last 50 seconds, fetal heart rate acceleration at the beginning of a contraction, and fetal heart rate deceleration to 110 beats/min before the peak of a contraction are all expected findings and do not need further intervention.

An infant is born in the breech position and assessment indicates the presence of Erb palsy (Erb-Duchenne paralysis). What clinical manifestation supports this conclusion? 1 Inability to turn the head to the unaffected side 2 Absence of the grasp reflex on the affected side 3 Absence of the Moro reflex on the unaffected side 4 Flaccid arm with the elbow extended on the affected side

4 With Erb-Duchenne paralysis there is damage to spinal nerves C5 and C6, which causes paralysis of the arm. The grasp reflex is intact because the fingers usually are not affected; if C8 is injured, paralysis of the hand results (Klumpke paralysis). There would be an absence of the Moro reflex only on the affected side. There is no interference with head turning; usually injury results from excessive lateral flexion of the head as the shoulder is born.

The nurse identifies a swelling on the scalp when assessing a newborn. What assessment finding indicates a cephalohematoma? 1 Unusually wide suture line 2 Ecchymotic area over the affected eye 3 Diffuse discoloration over the entire scalp 4 Swelling confined to the area over one skull bone

4

A client at term is admitted in active labor. She has tested positive for HIV. Which intervention in the standard orders should the nurse question as a risk to the fetus? 1 Sonogram 2 Nonstress test 3 Sterile vaginal examination 4 Internal fetal scalp electrod

4

A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential? 1 Fundal height 2 Obstetric history 3 Time of the last meal 4 Family history of bleeding disorders

1 It is vital that a baseline measurement be obtained, because increasing fundal height is a sign of concealed hemorrhage.Taking an obstetric history, ascertaining the time of the last meal, and asking about a family history of bleeding disorders are all appropriate assessments, but none is a priority at this critical time.

A nurse is assessing clients on the postpartum unit for pain. The client who will have more severe afterbirth pains is one who: 1 Is a grand multipara 2 Is a breastfeeding primipara 3 Had a vaginal birth for a first pregnancy 4 Had a cesarean birth at 43 weeks' gestation

1 A multipara's uterus tends to contract and relax spasmodically, even if the uterine tone is effective, resulting in pain that may require an analgesic for relief. Although breastfeeding increases the contractile state of the postpartum uterus, the breastfeeding primipara will not have the typical afterbirth pains of a multipara. Primiparas are less likely to have afterbirth pains than are multiparas. A cesarean birth has no effect on the development of afterbirth pains.

A client is to be discharged with her newborn, who was just circumcised. The nurse is planning discharge instructions about postcircumcision care. What should be included? 1 Apply diapers loosely. 2 Withhold feedings for 6 hours. 3 Cleanse the site with alcohol daily. 4 Expect some bleeding for 48 hours

1 Applying the diaper loosely for 2 or 3 days lessens pressure on the penis, thus promoting healing. The newborn may be fed as usual. Cleansing the site with alcohol daily would be painful and irritating to the wound. Bleeding is not expected, although the newborn should be monitored for signs of bleeding.

A client in the 38th week of gestation exhibits a slight increase in blood pressure. The health care provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position? 1 It increases blood flow to the fetus. 2 It decreases intra-abdominal pressure. 3 It increases the mean arterial pressure. 4 It prevents the development of thrombosis

1 The side-lying position decreases blood pressure and moves the gravid uterus off the great vessels of the lower abdomen, increasing venous return, improving cardiac output, and promoting kidney and placental perfusion. The side-lying position does not influence intra-abdominal pressure. While a pregnant woman is on bedrest the blood pressure decreases. The side-lying position does not prevent thrombosis; bedrest and immobility may increase the risk of thrombosis.

A nurse assessing a newborn suspects Down syndrome. Which characteristics support this conclusion? Select all that apply. 1 Hypotonia 2 Singe transverse palmar crease 3 High-pitched cry 4 Rocker-bottom feet 5 Epicanthal eye folds

125

A newborn weighing 9 lb 14 oz has a cesarean birth because of cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. What should the nurse do after the initial physical assessment? 1 Administer oxygen by hood. 2 Determine the blood glucose level. 3 Pass a gavage tube for a formula feeding. 4 Transfer the newborn to the neonatal intensive care unit

2 The simple measure of determining the infant's blood glucose level will reveal hypoglycemia in this large-for-gestational-age infant. There are no data that indicate a need for oxygen. Formula will not be given at this time, and there are no data that indicate a need for gavage feeding. The situation does not indicate the need for transfer of the newborn to the neonatal intensive care unit. The Apgar scores demonstrate that this infant is adapting to extrauterine life.

A client at 38 weeks' gestation is admitted with the diagnosis of placenta previa. What is the priority nursing care at this time? 1 Withholding oral intake 2 Assessing for hemorrhage 3 Avoiding extraneous stimuli 4 Encouraging supervised ambulation

2 To help prevent maternal and fetal complications the client must be continuously monitored for blood loss through inspections for external bleeding and counting and weighing of perineal pads. Withholding oral intake is not appropriate at this time but may become necessary if bleeding is continuous and profuse and a cesarean birth is imminent. There is no indication that the client has preeclampsia or that cerebral irritation is present, so avoidance of stimuli is not necessary in this scenario. As a means of minimizing further placental separation the client is kept on bedrest

A newborn's discharge from the hospital is being delayed because of a rising reticulocyte count. The infant's mother, who is being discharged, asks the nurse why her baby must stay. The nurse's response is based on an understanding that the infant must be observed for: 1 Bacterial infection 2 Significant jaundice 3 Bleeding tendencies 4 Adequate oxygenation

1 A rising reticulocyte count indicates accelerated erythropoietic activity that may reflect increased RBC destruction; increased RBC destruction increases the bilirubin level, causing jaundice. With an infection the sedimentation rate or WBC count, not the reticulocyte count, is increased. Although the reticulocyte count may be increased with chronic blood loss, there are no data to indicate that the infant is bleeding. This test does not reflect respiratory function.

Nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of: 1 4.5 2 5.5 3 6.5 4 7.5

4

In her 30th week of gestation, a 16-year-old primigravida whose usual blood pressure is 120/70 mm Hg has a blood pressure of 130/88 mm Hg. She is admitted to the birthing unit and says, "I don't know why the doctor's so worried about my blood pressure. The book I read says it's normal." The nurse should respond: 1 "Your doctor is being cautious." 2 "Your blood pressure is high for your age group." 3 "Your blood pressure is increased, according to pregnancy guidelines." 4 "That book is for older women, who have higher blood pressures."

3

nurse teaches a new mother about neonatal weight loss in the first 3 days of life. What does the nurse explain is the cause of this weight loss? 1 An allergy to formula 2 A hypoglycemic response 3 Ineffective feeding techniques 4 Excretion of accumulated excess flu

4 Early weight loss occurs because excess fluid is lost, not body mass. Weight loss is expected; there are no data to support an allergic response. Weight loss is not related to hypoglycemia. Neither breast nor formula feeding will prevent the 10% weight loss that is expected in the first few days of life.

Which of the following variables are scored on a biophysical profile? Select all that apply. 1 Fetal tone 2 Fetal position 3 Fetal movement 4 Amniotic fluid index 5 Fetal breathing movements 6 Contraction stress test results

1345

A pregnant client is concerned that she may have been infected with HIV. What information should a nurse include when counseling this client about HIV testing? Select all that apply. 1 The risks of passing the virus to the fetus 2 What positive or negative test results indicate 3 Discussing the risk factors for contracting HIV 4 The need for pregnant women to be tested for HIV 5 The emotional, legal, and medical implications of test results

125

A client is scheduled for amniocentesis. What should the nurse do before the procedure? 1 Give the client the prescribed sedative. 2 Remind the client to empty her bladder. 3 Prepare the client for an intravenous infusion. 4 Encourage the client to drink three glasses of water

2

A nurse is caring for a client who has been admitted with a tentative diagnosis of placenta previa. What procedure does the nurse anticipate? 1 Laparoscopy 2 Nonstress test 3 Amniocentesis 4 Ultrasound examination

4 Ultrasound is a noninvasive, relatively harmless way to visualize the location of the placenta. Laparoscopy is an invasive surgical procedure that is not used for this purpose. Nonstress testing provides information about the status of the fetus, not the location of the placenta. Amniocentesis is an invasive procedure that is used to remove amniotic fluid for fetal assessment.

A laboring client has asked the nurse to help her use a nonpharmacological strategy for pain management. Name the sensory simulation strategy. 1 Gently massage of the abdomen 2 Biofeedback-assisted relaxation techniques 3 Application of a heat pack to the lower back 4 Selecting a focal point and beginning breathing techniques

4Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.

A nurse knows that the newborns of mothers with diabetes often exhibit tremors, periods of apnea, cyanosis, and poor suckling ability. With what complication are these signs associated? 1 Hypoglycemia 2 Hypercalcemia 3 Central nervous system edema 4 Congenital depression of the islets of Langerhan

1

A primigravida at 34 weeks' gestation tells the nurse that she is beginning to experience some lower back pain. What should the nurse recommend that the client do? Select all that apply. 1 Wear low-heeled shoes. 2 Wear a maternity girdle during waking hours. 3 Sleep flat on her back with her feet elevated. 4 Perform pelvic tilt exercises several times a day. 5 Take an ibuprofen (Motrin) tablet at the onset of back pain.

14

he nurse teaches a client about the increased need for vitamin A to meet the demands imposed by rapid fetal tissue growth during pregnancy. Which foods should the nurse encourage the client to ingest to meet this increased need? Select all that apply. 1 Carrots 2 Citrus fruits 3 Fat-free milk 4 Sweet potatoes 5 Extra egg whites

14 Carrots provide the precursor pigment carotene, which the body converts to vitamin A. Sweet potatoes baked in the skin contain large amounts of carotene, which the body converts to vitamin A. Citrus fruits contain only a very small amount of vitamin A precursor. Fat-free milk contains only about half the needed vitamin A precursor. Egg whites contain no vitamin A precursor.

An infant born in the 36th week of gestation weighs 4 lb 3 oz (2062 g) and has Apgar scores of 7 and 9. What nursing actions will be performed on the infant's admission to the nursery? Select all that apply. 1 Recording of vital signs 2 Administration of oxygen 3 Offering a bottle of dextrose in water 4 Evaluation of the neonate's health status 5 Supportive measures to keep the neonate's body temperature stable

145

A client at the prenatal clinic has mild preeclampsia. What should the nurse teach her to do in regard to her fluid and nutritional intake? 1 Restrict fluid intake. 2 Stay on a low-salt diet. 3 Continue the pregnancy diet. 4 Increase carbohydrate consumption

3

A nurse is assessing a newborn with exstrophy of the bladder. What other defect associated with exstrophy of the bladder is of concern to the nurse? 1 Absence of one kidney 2 Congenital heart disease 3 Pubic bone malformation 4 Tracheoesophageal fistula

3 Incomplete formation of the pubic bone is associated with exstrophy of the bladder. Absence of one kidney, congenital heart disease, and tracheoesophageal fistula are not associated with exstrophy of the bladder.

One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score should the nurse assign to the newborn?

6 One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score should the nurse assign to the newborn?

Sitz baths are ordered for a client with an episiotomy during the postpartum period. A nurse encourages her to take the sitz baths because they aid the healing process by: 1 Promoting vasodilation 2 Cleansing perineal tissue 3 Softening the incision site 4 Tightening the rectal sphincte

1 Heat causes vasodilation and increased blood supply to the area. Cleansing is performed with a perineal bottle and cleansing solution immediately after voiding and defecation. Sitz baths do not soften the incision site. Neither relaxation nor tightening of the rectal sphincter will speed healing of an episiotomy.

During the initial assessment of a newborn the nurse suspects a congenital heart defect. Which clinical manifestations support this suspicion? Select all that apply. 1 Nasal flaring 2 Sternal retractions 3 Grunting respirations 4 Short periods of apnea 5 Cyanotic hands and feet 6 Heart rate of 160 beats/min

123 Nasal flaring occurs because of the stress of breathing; the flaring allows more air to enter the respiratory passages. Sternal retractions occur when accessory muscles of respiration contract during the stress of breathing. Grunting respirations occur as the glottis closes and reopens at the height of inhalation; this momentary closure of the glottis increases the time during which oxygen and carbon dioxide are exchanged in the alveoli. Newborns have irregular respirations with periods of apnea. Cyanosis of the hands and feet (acrocyanosis) is typical of all newborns at the time of birth. A heart rate of 160 beats/min is within the expected range of heart rates of healthy infants.

The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested? 1 Has several firm stools daily 2 Voids six or more times a day 3 Spits out a pacifier when offered 4 Awakens to feed about every four hours

2 The presence of at least six to eight wet diapers each day indicates sufficient breast milk intake. Several firm stools daily may indicate an inadequate amount of fluid ingestion; the stools of breastfeeding neonates should be soft to loose. Spitting out a pacifier is not an indication of adequate milk consumption; some infants need extra sucking stimulation. Awakening to feed every 4 hours is not a reliable indicator of adequate breast milk intake; sleep patterns vary.

When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with his or her own feelings about abortion, death, and loss so that he or she may: 1 Maintain control of the situation. 2 Share personal grief with the clients. 3 Allow the clients to express their grief. 4 Teach the clients how to cope effectively.

3

What behavior does a nurse expect of a newborn about 1 hour after birth? 1 Crying and cranky 2 Hyperresponsive to stimuli 3 Relaxed and sleeping quietly 4 Intensely alert with eyes wide open

3 It is expected that a newborn will enter a sleep phase about 30 minutes after birth. After the initial cry, the baby will settle down and become quiet and alert. Hyperresponsiveness to stimuli occurs after the first sleep. Intense alertness with eyes wide open occurs during the first period of reactivity.

t 1 minute after birth the nurse determines that an infant is crying, has a heart rate of 140 beats/min, has blue hands and feet, resists the suction catheter, and keeps the legs flexed and the arms extended. What Apgar score should the nurse assign? 1. 6 2. 7 3. 8 4. 9

3 The Apgar score is 8; 1 point is deducted for diminished muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which manifests as bluish hands and feet. Scores of 6 and 7 are too low and a score of 9 is too high.

A client who is pregnant for the first time asks the nurse about the changes in her body. While describing the changes in each body system, the nurse mentions that the system that undergoes the most profound change of all during pregnancy is the: 1 Urinary system 2 Endocrine system 3 Cardiovascular system 4 Gastrointestinal system

3 Total blood volume increases by 50%, making it necessary for the heart to pump harder and work more to accommodate this increase. Although the renal threshold is lowered, the major changes occur in the cardiovascular system. Changes in hormone levels occur, but they are not as profound as changes in the cardiovascular system. Pressure from the growing uterus can result in digestive discomfort and altered patterns of elimination, but these changes are not as significant as those in the cardiovascular system.

hile discussing dietary needs during pregnancy, a client tells the nurse, "I don't like to drink milk, because it makes me constipated." What should the nurse recommend? 1 Replacing nonfat milk with whole milk 2 Substituting a variety of cheeses for the milk 3 Dealing with constipation in some way other than omitting milk 4 Increasing the number of prenatal capsules to allow milk to be omitted

3 Unless a lactose intolerance is present, the client should drink milk; eating dried fruits and high-fiber foods and increasing fluids and activity will help ease constipation. Nonfat milk is not as beneficial as whole milk and will cause constipation as well. Cheeses can cause constipation. Taking more prenatal vitamins than recommended can be harmful and is not a substitute for milk.

23-year-old primigravida is at her first prenatal appointment today. Ultrasound indicates that she is at 9 weeks' gestation. She asks when she can first expect to feel her baby move. The best response by the nurse is: 1 "You should be able to feel the baby move any day now." 2 "You should feel your first light movement of the baby around 24 weeks." 3 "Most women can first detect movement of their babies by 12 to 14 weeks." 4 "Many women are able to first feel light movement between 18 and 20 weeks."

4

After an emergency cesarean birth, a neonate born at 35 weeks' gestation is admitted to the neonatal intensive care unit. The neonate has a Silverman-Anderson score of 6. What nursing intervention is needed? 1 Monitoring of cardiac status 2 Assessment of neurological reflexes 3 Ensuring increased caloric intake and fluids 4 Administration of respiratory support and observation

4 The Silverman-Anderson score is an index of neonatal respiratory distress. A Silverman-Anderson score of 6 does not reflect cardiac function, neurological status, or caloric need.

A client is found to have gestational hypertension in the 22nd week of gestation. What is a major complication of hypertensive disease associated with pregnancy that the nurse should anticipate? 1 Placenta previa 2 Polyhydramnios 3 Isoimmunization 4 Abruptio placentae

4 Vasospasms of placental vessels occur because of increased blood pressure, and the placenta may separate prematurely (abruptio placentae).

A nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result? 1 Dorsiflexion, then fanning 2 Hypertonia and jitteriness 3 An arched back and crying 4 An audible click on abduction

4As the head of the femur moves within the acetabulum, sometimes there is an audible click when there is developmental dysplasia of the hip. Dorsiflexion followed by fanning is associated with the Babinski test. Hypertonia and jitteriness is a neurological finding. An arched back and crying is opisthotonic posturing.

List the mechanisms of labor in the correct sequence. 1. Descent 2. Flexion 3. Extension 4. Expulsion 5. Restitution 6. Engagement 7. Internal rotation 8. External rotation

61273584 The cardinal movements of the mechanism of labor that occur in a vertex presentation are engagement, descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

newborn's birth was prolonged because the shoulders were very wide. With which reflex does the nurse anticipate a problem? 1 Moro 2 Plantar 3 Babinski 4 Steppin

1 A difficult birth because of broad fetal shoulders may result in a fractured clavicle, as evidenced by a knot or lump, limited arm movement, and a unilateral Moro reflex. Plantar reflex is unrelated to a difficult birth caused by a fetus with broad shoulders. Babinski reflex involves the feet; it is not related to a difficult birth caused by a fetus with broad shoulders. Stepping reflex involves the feet; it is not related to a difficult birth caused by a fetus with broad shoulders.

As a means of halting preterm labor a client is started on terbutaline (Brethine). For which side effect of this medication should the nurse monitor the client? 1 Bradycardia 2 Hyperkalemia 3 Widening pulse pressure 4 Hypotonic uterine contractions

3

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include? 1 A schedule for teaching infant care 2 A demonstration and explanation of infant care 3 A discussion of mothering skills presented in a nonthreatening manner 4 Emotional support and that will foster dependence on the nurse's expertis

2

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply. 1 Tense fontanels 2 High-pitched crying 3 Apgar score of less than 5 4 A defect in the lumbosacral area 5 Head circumference 2 cm greater than the chest circumference

124 An excessive amount of cerebrospinal fluid associated with hydrocephalus causes tense fontanels. A shrill, high-pitched cry often accompanies progressive hydrocephalus and other neurologic problems. Infants with hydrocephalus may or may not have low Apgar scores. Hydrocephalus complicates approximately 90% of lumbosacral meningomyeloceles. Head circumference 2 cm greater than the chest circumference is expected in a newborn.

The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol syndrome (FAS) in the newborn? Select all that apply. 1 Hypotonia 2 Polydactyly 3 Umbilical hernia 4 Hypoplastic maxilla 5 Small, upturned nose

145 Hypotonia is associated with FAS, as well as with Down syndrome. A receding chin (hypoplastic maxilla) is associated with FAS. The typical facies associated with FAS also usually includes a small, upturned nose, which is distinctive in these infants. Polydactyly (extra fingers) is associated with the trisomies. An umbilical hernia can develop in early infancy and is not related to FAS.

A client at 7 weeks' gestation tells a nurse in the prenatal clinic that she is sick every morning with nausea and vomiting and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of the: 1 Fifth month 2 Third month 3 Fourth month 4 Second month

2

A client at 9 weeks' gestation asks the nurse in the prenatal clinic whether she may have chorionic villi sampling (CVS) performed during this visit. What should the nurse keep in mind as the optimal time for CVS while formulating a response? 1 At 8 weeks but no later than 10 weeks 2 At 10 weeks but no later than 12 weeks 3 At 12 weeks but no later than 14 weeks 4 At 14 weeks but no later than 16 weeks

2

A client at 16 weeks' gestation calls the nurse at the prenatal clinic and states that her partner just told her that he has genital herpes. What should the nurse include when teaching the client about sexual activity? 1 Condoms must be used when the couple is having intercourse. 2 Sexual abstinence should be practiced during the last 6 weeks. 3 It will be necessary to refrain from sexual contact during pregnancy. 4 Meticulous cleaning of the vaginal area after intercourse is essential

22 Abstinence during the 4 to 6 weeks before term is the best way to avoid contracting the virus and having an outbreak before the birth. Because the herpes virus is smaller than the pores of a condom, this type of protection has limited effectiveness. Abstinence is necessary only when disease symptoms are present in the partner and during the last 4 to 6 weeks of pregnancy. Washing is not sufficient to prevent contraction of this virus; contact already has been made.

A client participated in caring for her infant in the neonatal intensive care unit for several days in preparation for the infant's discharge. On the day of discharge she arrives at the unit with an alcohol odor on her breath and slurred speech. What is the most appropriate action by the nurse? 1 Asking her to wait in the hospital lobby and calling the practitioner to cancel the discharge prescription 2 Explaining to her that the social worker will be called to discuss having her infant discharged to a foster home 3 Talking with her about her condition while assessing her willingness to participate in an alternate plan for discharge 4 Telling her that discharge will take place but that a home health nurse will visit to assess how she is caring for her infant

3

A pregnant client with a history of heart disease asks how she can relieve her occasional heartburn, and the nurse teaches her self-care measures. What statement indicates to the nurse that the client understands the teaching? 1 "I should lie down an hour after I eat." 2 "I shouldn't drink more than a quart a day." 3 "I won't take antacids that contain sodium." 4 "I plan to eat three evenly spaced meals throughout the day."

3

A primipara tells the nurse that her baby is breathing very rapidly and that the breaths are irregular. She expresses fear that her baby may be sick and will have to remain in the hospital. What is the nurse's initial action? 1 Assessing the infant and tell the mother that her baby is fine 2 Picking the infant up and telling the mother that the nurses will watch her baby closely 3 Observing the infant's respirations and telling the mother that these respirations are expected 4 Taking the infant to the nursery and returning to tell the mother that the health care provider has been notified

3

A nurse is assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate? 1 Hypotension 2 Decreased fetal heart rate 3 Unusual uterine enlargement 4 Painless, heavy vaginal bleeding

3 The proliferation of trophoblastic tissue filled with fluid causes the uterus to enlarge more quickly than if a fetus were in the uterus. Hypertension, not hypotension, often occurs with a molar pregnancy. There is no fetus within a hydatidiform mole. There may be slight painless vaginal bleeding.

A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. What complication does the nurse suspect? 1 Tetany 2 Spina bifida 3 Hyperkalemia 4 Intracranial hemorrhage

4

A couple in their late 30s, expecting their first child, plans to have an amniocentesis. At what point in the pregnancy should the nurse tell the couple that the test it will be scheduled? 1 When quickening is felt 2 During the last trimester 3 At the 10th week of gestation 4 After the 14th week of pregnancy

4

A nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply. 1 Sneezing 2 Hyperactivity 3 High-pitched cry 4 Exaggerated Moro reflex

123 Neurological signs of withdrawal in a neonate of an opioid-addicted mother are manifested by sneezing. Other signs exhibited by neonates undergoing withdrawal are hyperactivity and jitteriness and a shrill, high-pitched cry. The Moro reflex usually becomes weaker as the signs of withdrawal become apparent. The deep tendon reflexes are exaggerated during opioid withdrawal.

nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply. 1 Pallor 2 Irritability 3 Hypotonia 4 Ineffective sucking 5 Excessive birth weigh

234 An inadequate amount of cerebral glucose causes irritability and restlessness. Hypoglycemia affects the central and peripheral nervous systems, resulting in hypotonia. Feeding difficulties are due to hypoglycemic effects on the fetal central nervous system. Hypoglycemia causes cyanosis, not pallor, in the newborn. Excessive birthweight is common but does not indicate hypoglycemia.

A nurse is obtaining a health history from a primigravida on her first visit to the prenatal clinic. Before discussing the client's health habits with her, what does the nurse consider the most important factor in the survival of the client's newborn? 1 Reproductive history 2 Adequacy of prenatal care 3 Health habits and social class 4 Gestational age and birthweight

4

A pregnant single client who is attending a crisis intervention group has finally decided to go through with the pregnancy and keep the baby. What is the crisis intervention nurse's primary responsibility at this time? 1 Confirming that this really is what the client wants to do 2 Exploring other problems that the client may be experiencing 3 Selecting a health care provider that the client can visit for prenatal care 4 Providing information about resources from which the client may receive assistance

4

nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. What part of the foot is the best site to use for the puncture? 1 Big toe 2 Foot pad 3 Inner sole 4 Outer hee

4

A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is the best gauge for the client to use? 1 Number of clots that were passed 2 Changes in fetal activity when bleeding 3 Increased weakness since bleeding began 4 Amount of blood lost in relation to usual menstrual flo

4Determining the amount of blood lost in relation to her usual menstrual flow gives the client a familiar gauge with which to estimate the amount of bleeding she is experiencing. The presence of clots does not indicate the amount of bleeding. Changes in fetal activity may indicate a problem, but there is no relationship to the amount of bleeding. Weakness is a subjective symptom and may not reflect blood loss.

A nurse suspects that a preterm neonate, who is being fed by means of gavage, may have necrotizing enterocolitis (NEC). What clinical manifestation of NEC did the nurse identify? 1 Increased number of explosive stools 2 Circumoral pallor that develops during feeding 3 Several episodes of projectile vomiting of formula 4 Large amounts of residual formula withdrawn before a feedin

4Primary manifestations of NEC include feeding intolerance, an increased gastric residual volume of undigested formula, and bile-stained emesis. An increased number of explosive stools occurs with diarrhea; stools of infants with NEC are generally reduced in number and contain glucose and blood. Circumoral pallor that develops during a feeding may occur with a cardiac anomaly, not NEC. Pyloric stenosis, not NEC, may involve several episodes of projectile vomiting of formula.

A nurse performing a newborn assessment elicits the Babinski reflex. The nurse concludes that finding indicates: 1 Hypoxia during labor 2 Neurological injury during birth 3 Hyperreflexia of the muscular system 4 Immaturity of the central nervous system (CNS)

4Stimulation of the newborn's immature neuromuscular system causes dorsiflexion of the big toe and fanning of the remaining toes (Babinski sign). CNS damage resulting from hypoxia may manifest as a lack of Babinski sign. Hyperreflexia is an abnormal increase in reflexes; it is not related to the Babinski reflex.

One minute after birth a neonate has a weak cry, a heart rate of 90 beats/min, some flexion of the extremities, grimacing, and acrocyanosis. What is the Apgar score for this neonate?

5

While assessing a neonate the nurse observes ecchymotic-appearing areas on the buttocks and sacrum. The nurse concludes that this discoloration is probably related to the neonate's: 1 Skin color 2 Gestational age 3 Tendency to bleed 4 Vaginal breech birth

1 These bluish discolorations are Mongolian spots, which are commonly found on the back and buttocks of dark-skinned newborns. These spots are unrelated to gestational age. Bluish spots on the buttocks are not areas of ecchymosis areas caused by bleeding. The buttocks and genitals of infants who are born vaginally in the breech presentation are usually edematous.

A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy? 1 Fetal growth 2 Fluid retention 3 Metabolic alterations 4 Increased blood volume

1 Weight gain during pregnancy averages 25 to 35 lb (11.3 to 15.8 kg); of this amount, the fetus accounts for 7 to 8 lb (3.2 to 3.6 kg), or approximately 30%. Fluid retention accounts for 20% to 25% of weight gain. Metabolic alterations do not cause weight gain. Increased blood volume accounts for 12% to 16% of weight gain.

A client at 39 weeks' gestation is admitted for induction of labor. Knowing that several medications are used to induce labor, a nurse identifies those that may be prescribed. Select all that apply. 1 Oxytocin (Pitocin) 2 Misoprostol (Cytotec) 3 Ergonovine (Ergotrate) 4 Carboprost (Hemabate) 5 Dinoprostone (Prepidil

125 Oxytocin (Pitocin) is an oxytocic that triggers or augments uterine contractions; it is used for labor induction. Misoprostol (Cytotec) is a prostaglandin used for cervical ripening and labor induction. Dinoprostone (Prepidil) is used for cervical ripening to induce labor and is also used to induce abortion. Ergonovine (Ergotrate) is an oxytocic used in postpartum or postabortion hemorrhage. Carboprost (Hemabate) is a prostaglandin used to treat postpartum hemorrhage; it is also used to induce abortion.

omen who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for what complications? Select all that apply. 1 Seizures 2 Preterm labor 3 Multiple gestation 4 Chromosomal anomalies 5 Bleeding in the first trimester

2345 Increased risk for preterm labor is age associated; it occurs more commonly in older primigravidas and adolescents. Mature women have an increased incidence of multiple gestations as a result of fertility drug use and in vitro fertilization. After 35 years of age, mature women have an increased risk of having children with chromosomal abnormalities. Bleeding in the first trimester as a result of spontaneous abortion occurs more frequently in mature gravidas. Seizures are not seen more frequently in mature gravidas.

A client at 37 weeks' gestation arrives at the emergency department stating that she is experiencing abdominal pain but no vaginal bleeding. The health care provider diagnoses abruptio placentae. The client asks the nurse why it is so painful. What should the nurse consider as the initial cause of the abdominal pain before responding in language that the client will understand? 1 Hemorrhagic shock 2 Concealed hemorrhage 3 Blood in the myometrium 4 Disseminated intravascular coagulation

2The blood cannot escape from behind the placenta; the abdomen becomes boardlike and painful because of the entrapment of blood.

A primigravida at 38 weeks of gestation presents to the clinic with a blood pressure of 142/94, edema in all extremities, and a weight gain of five pounds since the previous checkup one week ago. The client has delivered and is receiving magnesium sulfate postpartum. The priority during the immediate four hours after delivery would be: 1 Monitoring blood pressure 2 Monitoring urinary output 3 Observing amount of lochia 4 Assessing breastfeeding technique

3 4th stage of labor-high risk of hemorrhage. due to low platelet with preeclampsia

A male newborn has been exposed to HIV in utero. Which assessment supports the diagnosis of HIV infection in the newborn? 1 Delay in temperature regulation 2 Continued bleeding after circumcision 3 Hypoglycemia within the first day of birth 4 Thrush that does not respond readily to treatme

4

An unmarried pregnant adolescent who is attending a crisis intervention group has decided to continue the pregnancy and keep the baby. Now the crisis intervention nurse's primary responsibility is to: 1 Praise the client for making a wise decision. 2 Explore other problems that the client is experiencing. 3 Make an appointment for the client to visit a prenatal clinic. 4 Provide information about where the client will be able to get assistance.

4

A nurse assesses the frequency of a client's contractions by timing them from the beginning of a contraction until the: 1 Uterus starts to relax 2 End of a second contraction 3 Uterus has relaxed completely 4 Beginning of the next contraction

4Timing until the beginning of the next contraction is the accepted way of determining the frequency of contractions. The time between beginning of a contraction and when the uterus starts to relax is not an indication of the duration of a contraction. The time from the beginning of a contraction to the end of a second one does not reflect the frequency of contractions. Complete relaxation of the uterus indicates the end of a contraction, but measuring the time from the beginning of the contraction until relaxation occurs is not the accepted way of timing the frequency of contractions.

While performing bag-and-mask ventilation on a newborn, a nurse does not see the newborn's chest rise. Place the following interventions in order of their priority. 1. Reposition the head. 2. Open the mouth slightly. 3. Apply the mask for a better seal. 4. Assess the neonate's response to these measures. 5. Suction the mouth if there are secretions.

51234

Organize the steps in infant cardiopulmonary resuscitation (CPR) in the correct sequence. 1. Check the pulse at the brachial artery. 2. Initiate chest compressions in a 30:2 ratio. 3. Position the infant supine on a firm, flat surface. 4. Initiate rescue breathing at a rate of 40 to 60 breaths/min. 5. Note the infant's color and tap or gently shake the shoulders. 6. Open the airway with the head tilt-chin lift method and listen for exhalation.

536412?? The steps in infant CPR are assess responsiveness, position the infant, open the airway, assess breathing, initiate breathing, assess circulation, initiate compressions.

Pregnant women with cardiac problems must be assessed frequently. Which adaptation does the nurse suspect is the result of early decompensation? 1 Hemoptysis 2 Tachycardia 3 Increasing fatigue 4 Generalized edema

3 Increasing fatigue is one of the early signs of decompensating resulting from an increased cardiac workload. Hemoptysis is a later sign of cardiac decompensation that is associated with pulmonary edema. Tachycardia and generalized edema are later signs of cardiac decompensating and may be accompanied by other signs of heart failure.

A client at 40 weeks' gestation is admitted to the birthing unit and an amniotomy is performed to facilitate labor. What is first action after the nurse determines that the umbilical cord has not prolapsed? 1 Assessing the fetal heart rate 2 Obtaining the maternal vital signs 3 Turning the client on her left side 4 Monitoring the frequency of contractions

1 Once cord prolapse and consequent cord compression have been ruled out, it is imperative to evaluate the effect of the amniotomy on the fetus. Obtaining the maternal vital signs is not the priority; it can be done later. Although turning the client on her left side is important, fetal well-being is the priority concern. There are no data to indicate that contractions have started.

A client at 36 weeks' gestation is admitted to the high-risk unit with heavy bleeding because of placenta previa. The nurse places the client in a lateral Trendelenburg position to: 1 Prevent shock 2 Control bleeding 3 Keep pressure off the cervix 4 Move the placenta off the cervix

1 The Trendelenburg position shunts blood to the upper body and vital organs. The Trendelenburg position will not help control the bleeding. Pressure on the cervix is thought to have no bearing on bleeding episodes. In late pregnancy the placenta does not change its location in the uterus. Also, the Trendelenburg position cannot move the placenta from the cervix.

Phenylketonuria (PKU) testing is performed on a newborn. The nurse plans to explain to the mother the purpose of this screening test. What does this test reveal? 1 Whether the infant is positive for PKU 2 Whether the mother is a carrier of PKU 3 The mother's risk for later development of PKU 4 The infant's risk for development of PKU later in life

1 The major purpose of this screening test is to determine whether the infant has phenylketonuria (PKU), which can be detected after the infant has started feedings. Determining whether the mother is a carrier for PKU is not the objective of the test for PKU. Epidemiological information is a purpose of genetic screening; in this instance the most important determination is whether the infant has PKU. Risk for later development of the disorder is not the purpose of PKU testing; it is to determine whether the neonate has the disorder.

During a client's first visit to the prenatal clinic, a nurse discusses a pregnancy diet. The client states that her mother told her that she should restrict her salt intake. What is the nurse's best response? 1 "Your mother is always correct. You should use less salt to prevent swelling during pregnancy." 2 "Because you need salt to maintain body water balance, it is not restricted. Just eat a well-balanced diet." 3 "Salt is an essential nutrient that is naturally reduced by the body's estrogen. There's no reason to restrict salt in your diet." 4 "We no longer recommend that salt intake be as restricted as much as in the past, but you still shouldn't add salt to your food."

2

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? 1 Stimulating crying 2 Suctioning the airway 3 Using an Ambu bag with oxygen support 4 Placing the infant in the reverse Trendelenburg position

2

The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding? 1 Most important is diagnosis within 2 days after birth. 2 Most important is the institution of a corrective formula soon after birth. 3 It depends on whether phenylpyruvic acid is found in the urine 1 week after birth. 4 It depends on the level of phenylalanine found in the blood immediately after birth.

2

A nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal? Select all that apply. 1 Tachypnea 2 Relaxed muscle tone 3 Exaggerated Moro reflex 4 Prolonged, high-pitched cry 5 Restlessness and excessive activity 6 Strong sucking and swallowing reflex

1345 In addition to these symptoms, an infant experiencing drug withdrawal has muscle rigidity with increased muscle tone and poor sleep patterns. Such infants are often difficult to console.

What does an Apgar score recorded 5 minutes after birth help the nurse evaluate? 1 Gestational age of the newborn 2 Effectiveness of the birthing process 3 Adequacy of the transition to extrauterine life 4 Possibility of respiratory distress syndrome

3

When changing her newborn's diaper a new mother notes a reddened area on the infant's buttock and reports it to the nurse. What should the nurse do next? 1 Have nursery staff members change the infant's diaper. 2 Use both lotion and powder to protect the involved area. 3 Request that the practitioner prescribe a topical ointment. 4 Encourage the mother to cleanse the area and change the diaper more often.

4 Frequent cleansing and diaper changes will limit the presence of irritating substances. Having the nurses change the diaper may lower the mother's self-esteem. Powder and lotion will cake and retain moisture in the area. Requesting that the health care provider prescribe a topical ointment is a nursing, not a medical, problem.

A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute? 1 Color 2 Heart rate 3 Respirations 4 Reflex irritability

1 Because of inadequate peripheral circulation at birth there is acrocyanosis (body pink, hands and feet blue), which merits 1 point for color. This is a common occurrence in a healthy newborn. The fetal heart rate ranges from 110 to 160 beats/min; a newborn heart rate of more than 100 beats/min is expected in a healthy newborn and merits 2 points. An adequate respiratory rate is evidenced by crying, which is expected in a healthy newborn and merits 2 points. Reflex irritability is represented by crying, which is expected in a healthy newborn and merits 2 points.

An infusion of oxytocin is administered to a client for induction of labor. After several minutes the uterine monitor indicates contractions lasting 100 seconds with a frequency of 130 seconds. What is the next nursing action? 1 Discontinuing the infusion 2 Checking the fetal heart rate 3 Slowing the oxytocin flow rate 4 Turning the client on her left side

1 Contractions lasting too long and occurring too frequently can lead to fetal hypoxia; stopping the oxytocin infusion should stop the contractions, thereby increasing oxygen flow to the fetus. The fetal heart rate should be monitored, but this is not the priority. Oxytocin (Pitocin) will continue to promote uterine contractions; this is unsafe because the prolonged, frequent contractions decrease oxygen flow to the fetus. Turning the client on her left side will promote placental perfusion, but it is not the priority at this time.

The postpartum nurse has just received report on four clients. Which client should the nurse care for first? 1 Client who vaginally delivered a 7-lb baby 1 hour ago 2 Client who vaginally delivered a 9-lb baby 1 hour ago 3 Client who vaginally delivered a preterm baby 4 hours ago 4 Client who had a planned cesarean delivery of an 8-lb baby 2 hours ago

2 The nurse should assess the client at risk for postpartum hemorrhage first. Uterine atony after a vaginal delivery is the main cause of postpartum hemorrhage. An overdistended uterus caused by a large fetus (9-lb baby) can cause uterine atony. Delivering a 7-lb baby or a preterm baby is not a risk factor. Uterine atony is minimized in a planned cesarean delivery.

A pregnant client with cardiac disease asks a nurse to clarify what she was told about making the birth easier for her. What should the nurse remind her is an option to facilitate birth? 1 Inducing labor with Pitocin 2 Scheduling a cesarean birth 3 Monitoring an unassisted vaginal birth 4 Facilitating the birth with vacuum extraction

4 Vacuum extraction will decrease the workload of the heart during expulsion and permit a vaginal birth. Induction can increase cardiac workload. Many clients with cardiac disease are able to give birth vaginally when precautionary measures are instituted; it is preferable to avoid the secondary stress that surgery may impose. During the second stage of labor cardiac output may be increased; the client needs assistance to decrease the cardiac workload.

The parents of a newborn decide not to have their son circumcised. What should the nurse's discharge teaching for the care of an uncircumcised neonate include? 1 "Check the penis for bleeding." 2 "Apply petrolatum to the end of the penis." 3 "Pull the foreskin back toward the shaft of the penis." 4 "Clean the penis with warm water without moving the foreskin."

4 Washing removes urine and feces; a tight prepuce (foreskin) is common in newborns and may not be retractable for 3 to 4 years. An uncircumcised penis should not bleed. Applying petrolatum to the end of the penis may be recommended after a neonate has been circumcised to prevent adherence of the penis to the diaper. Pulling the foreskin back toward the shaft of the penis may cause problems with constriction around the penile shaft and is not recommended.

While reviewing laboratory results of clients seen at a maternity clinic, the nurse notes that one client's maternal serum α-fetoprotein level is lower than is typical. The nurse recognizes that this may be associated with: 1 Fetal demise 2 Down syndrome 3 Neural tube defects 4 Esophageal obstruction

2 others asso with increase

A pregnant client asks a nurse for information about toxoplasmosis during pregnancy. What should the nurse teach the client about how to prevent the transmission of toxoplasmosis? 1 Pork and beef should be cooked well before being eaten. 2 Salads with mayonnaise dressing should be avoided during the summer. 3 Raw shellfish are intermediary hosts and should be avoided during pregnancy. 4 Toxoplasmosis is a disease that is prevalent in underdeveloped countries, not in developed ones.

1

While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation and lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information? 1 G5 T1 P1 A2 L2 2 G4 T1 P1 A2 L2 3 G4 T2 P0 A0 L2 4 G5 T2 P1 A1 L2

1

A nurse teaches the warning signs that should be reported throughout pregnancy. Which statement by the client indicates an understanding of the prenatal instructions? 1 "I'll call the clinic if I have abdominal pain." 2 "Mild, irregular contractions mean that my labor is starting." 3 "I need to call the clinic if my ankles start to swell at night." 4 "A whitish vaginal discharge means that I'm getting an infection."

1

A 23-year-old woman arrives at the prenatal clinic because she thinks that she is pregnant. Her last menstrual period began on March 31, and her pregnancy test reveals a positive result. According to Nägele's rule, what is this client's expected date of birth (EDB)? 1 July 8 2 January 7 3 December 7 4 December 24

2

Which assessment findings of a child would indicate a need for genetic consultation? Select all that apply. 1 Fetal alcohol syndrome 2 Visual or hearing problems 3 Family history of mental illness 4 Development and speech delays 5 Excessive bleeding or excessive clotting

2345 Visual or hearing problems may indicate a genetic disorder and should be assessed thoroughly. Mental illness is a hereditary disorder that can be transmitted through genes to the child. Therefore, a family history of any mental illness indicates a need for genetic consultation so that preventive measures and treatment can be initiated. Development and speech delays may indicate a genetic disorder, like autism or another behavioral disorder. Bleeding disorders like sickle cell anemia are also inherited and need genetic consultation. Fetal alcohol syndrome is not inherited, but caused by maternal consumption of alcohol during pregnancy.

The nurse manager receives report on the following laboring clients. Which client should the nurse see first? 1 G2 P0 with SROM at 7 cm of dilation 2 G2 P1 with SROM in the active phase 3 G1 P0 with intact membranes in the latent phase 4 G6 P5 with intact membranes at 5 cm of dilation

4 A grand multipara (five or more births) is at greater risk for a precipitate labor and should be monitored more closely than a client with fewer deliveries and no other major risk factors.

A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse what foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply. 1 Beef and fish 2 Milk and cheese 3 Chicken and turkey 4 Black and pinto beans 5 Enriched bread and pasta

45

Select all that apply. 1 Chloasma 2 Linea nigra 3 Effacement 4 Morning sickness 5 Cervical softening 6 Urinary frequency

12 Melanocyte-stimulating hormone during pregnancy causes pigmentation over the bridge of the nose and cheeks (chloasma, mask of pregnancy). The concentration of melanocyte-stimulating hormone increases from the end of the second month of pregnancy until term, causing in some women a line of pigmentation on the abdomen from the umbilicus to the symphysis pubis (linea nigra). Effacement of the cervix is a result of increased mucoidal secretion and the effects of labor. A high level of chorionic gonadotropin, secreted by the placental chorion, is associated with the nausea and vomiting that may occur early in pregnancy. Cervical softening of the cervix occurs as a result of increased mucoidal secretions and the effects of labor. Urinary frequency is related to advancing growth and pressure of the uterus on the bladder.

A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy because she had planned to go back to work when her youngest child started school next year. What developmental task of pregnancy must the woman accomplish in the first trimester of pregnancy? 1 Recognize her ambivalence. 2 Accept that she is pregnant. 3 Prepare for the birth of the baby. 4 Recognize the fetus as an individual separate from the mother.

2

Sonography of a primigravida who is at 15 weeks' gestation reveals a twin pregnancy. The nurse reviews with the client the risks of a multiple pregnancy that were explained by the health care provider. Which condition does the client identify that indicates the need for further instruction about complications associated with a multiple gestation? 1 Preterm birth 2 Down syndrome 3 Twin-to-twin transfusion 4 Gestational hypertension

2

The school nurse is teaching a group of 16-year-old girls about the female reproductive system. One student asks how long after ovulation it is possible for conception to occur. The most accurate response by the nurse is based on the knowledge that an ovum is no longer viable after: 1 12 hours 2 24 hours 3 48 hours 4 72 hours

2 The most common error made by women taking home pregnancy tests is to perform the test too early in the pregnancy. Although some tests may be accurate at 7 days, the test will be more accurate if the test is performed at the time of the missed period. Saturation of the test strip and using the first void of the morning are necessary steps in the process. Taking a prescribed tranquilizer is more likely to cause a false-positive result.

A 38-year-old client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply? 1 Trisomy 21 2 Turner syndrome 3 Open neural tube defects 4 Chromosomal aberrations

3

The nurse is caring for a client whose fetus is in a breech presentation. Suddenly the membranes rupture and meconium appears in the vaginal introitus. The nurse realizes that this: 1 Indicates that the cord will prolapse 2 Is evidence of fetal heart abnormalities 3 Is a common occurrence in breech presentations 4 Requires immediate notification of the practitioner

4 Sudden rupture of membranes followed by the appearance of meconium occurs in breech presentation when pressure on the fetal abdomen from the contractions forces meconium from the bowel. Cord prolapse is not an absolute, but it may occur if the presenting part does not fill the pelvic cavity. Fetal heart abnormalities are identified by means of auscultation or continuous electronic fetal monitoring, not by the presence of meconium. Immediate notification of the practitioner is unnecessary.

A nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her about minimizing breast discomfort? 1 Apply covered ice packs to the breasts. 2 Gently apply cocoa butter to the nipples. 3 Place warm, wet washcloths on the nipples. 4 Manually express colostrum from the breasts.

1

The sonogram of a woman in her 24th week of gestation reveals a partial placenta previa. What is the most important clinical finding for the nurse to identify as the client's pregnancy progresses? 1 Vaginal bloody seepage 2 Preterm labor contractions 3 Sudden sharp abdominal pain 4 Premature rupture of membranes

1

What is the initial nursing objective for a grand multipara who has had a cesarean birth? 1 Prevention of hemorrhage 2 Promotion of wound healing 3 Avoidance of wound dehiscence 4 Establishment of mother-infant bonding

1

A client's labor has progressed to the point where she is dilated 6 cm dilated, but the fetal head is not engaged. An amniotomy is performed. After this procedure, the nurse checks the fetal heart rate. What other nursing action should be performed at this time? 1 Inspecting the perineum 2 Preparing for an immediate birth 3 Measuring the maternal blood pressure 4 Increasing the intravenous fluid rate

1 After the rupture of membranes, the umbilical cord may prolapse if the fetal head does not engage immediately, and this can lead to fetal compromise. The perineal area should be inspected at this time and frequently thereafter for evidence of cord prolapse. Rupture of the membranes does not lead to precipitous birth; it is done to facilitate labor. Rupture of membranes is not associated with maternal blood pressure changes. Increasing the IV rate is appropriate if the client shows signs of dehydration; the data do not indicate this.

The nurse is performing the nursery intake assessment of a 1-hour old newborn. The assessment reveals that the newborn's hands and feet are cyanotic and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings? 1 Notify the practitioner, because circumoral pallor may indicate cardiac problems. 2 Notify the practitioner, because both signs are indicative of increased intracranial pressure. 3 Take no specific action, because both signs are expected in a newborn until 2 weeks of age. 4 Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying.

1 Although acrocyanosis (cyanotic hands and feet) is common in the newborn, circumoral pallor is not a normal newborn finding. Circumoral pallor is one sign of cardiac pathology and indicates a need for further assessment and investigation by the healthcare provider. Neither circumoral pallor nor acrocyanosis is a sign of increased intracranial pressure. Circumoral pallor is not expected in the newborn; it may indicate cardiac pathology.

nurse is assessing a newborn born after 32 weeks' gestation. What clinical finding does the nurse anticipate? 1 Barely visible areola and nipple 2 Zero-degree square window sign 3 Pinnae that spring back when folded 4 Palms and soles with clearly defined creases

1 Breast tissue is not developed or palpable in an infant of less than 33 weeks' gestation. The pinnae spring back after being folded in an infant of 36 weeks' gestation. Creases in the palms and on the soles are not clearly defined until after the 37th week of gestation. A zero-degree square window sign is present in an infant of 40 to 42 weeks' gestation.

After an unexpected emergency cesarean birth the client tells the nurse, "I failed natural childbirth." Which postpartum phase of adjustment does this statement most closely typify? 1 Taking-in 2 Letting-go 3 Taking-hold 4 Working-through

1 By discussing the experience, the client is bringing it into reality; this is characteristic of the taking-in phase. The client is not ready to assume the tasks of the letting-go phase until completing the tasks of the taking-in and taking-hold phases. The taking-hold phase is marked by an increased desire to resume independence; this statement reveals that the client is not ready for this phase. The working-through phase is not a separate phase of adjustment to parenthood; it is not relevant.

When assessing a newly admitted primigravida in labor, a nurse determines that the fetal heartbeat is loudest in the upper left quadrant. What fetal position does the nurse identify? 1 Left sacral anterior 2 Left mentum anterior 3 Left occipital anterior 4 Left occipital transverse

1 If the fetal heartbeat is heard in the upper left quadrant, the fetus must be lying in a breech position with the head upright and the heart uppermost. Fetal heart tones are heard best in the lower quadrants of the abdomen in cephalic presentations.

A client and her partner are working together during the woman's labor. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the partner to do that will alleviate the client's discomfort during contractions? 1 Deep-breathe slowly. 2 Perform pelvic rocking. 3 Use the panting technique. 4 Begin patterned, paced breathing

1 Slow, deep breathing expands the spaces between the ribs and raises the abdominal muscles, giving the uterus room to expand and preventing painful pressure of the uterus against the abdominal wall. Pelvic rocking is used to relieve pressure from back labor. Panting is used to halt or delay the expulsion of the infant's head before complete dilation has occurred. Patterned, paced breathing is used during the transition phase of the first stage; the client has not yet reached this phase.

A nurse is caring for a new mother who has a chlamydial infection. For which complications should the nurse assess the client's neonate? Select all that apply. 1 Pneumonia 2 Preterm birth 3 Microcephaly 4 Conjunctivitis 5 Congenital cataract

124 Pneumonia may develop in the newborn with a chlamydial infection; oral antibiotics such as erythromycin may be required. Preterm birth is a common complication of chlamydial infection. Ophthalmia neonatorum (neonatal conjunctivitis) is common in newborns whose mothers have chlamydial infection; ophthalmic antibiotic ointments are administered to all newborns prophylactically. Microcephaly is more likely to occur in newborns with severe infections of toxoplasmosis or cytomegalovirus. Cataracts may occur in a newborn whose mother had rubella during pregnancy. q

A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply. 1 Small breast buds 2 Wrinkled thin skin 3 Multiple sole creases 4 Presence of scrotal rugae 5 Pinnae that remain flat when folded

125 Breast buds are small, with underdeveloped nipples, in the preterm infant. Preterm newborns have little subcutaneous fat; the skin is wrinkled and blood vessels and bony structures are visible. Preterm infants' ears contain little cartilage and are very inelastic when folded; at term, the ears contain cartilage and the pinnae are firm. Sole creases develop progressively during pregnancy and cover the entire foot at term. A preterm male infant's testes are undescended; rugae develop progressively and cover the entire scrotum of the full-term male newborn.

A woman is being seen in the prenatal clinic at 36 weeks' gestation. The nurse is reviewing signs and symptoms that should be reported to health care provider with the mother. Which signs and symptoms require further evaluation by the health care provider? Select all that apply. 1 Decreased urine output 2 Blurred vision with spots 3 Urinary frequency without dysuria 4 Heartburn after eating a fatty meal 5 Contractions that are regular and 5 minutes apart 6 Shortness of breath after climbing a flight of stairs

125 Decreased urine output, blurred vision, and severe headache may occur with pregnancy-associated hypertension. Contractions that become regular are associated with the onset of labor. Preparatory (Braxton Hicks) contractions ease when the client walks. Swelling of the face and hands is a warning sign. Urinary frequency occurs in the first trimester and again in the third trimester as the uterus settles back into the pelvis. The weight of the uterus may delay emptying of the stomach and make heartburn a more frequent problem. Shortness of breath would be expected after the client climbs a flight of stairs.

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? Select all that apply. 1 Long nails 2 Wrinkled skin 3 Edematous skin 4 Abundant body hair 5 Obvious blood vessels in the skin

12 The longer the nails, the more mature the infant. Wrinkled skin is found in a postterm infant who has been exposed to amniotic fluid for too long; the skin is thick, parchmentlike, wrinkled, and peeling. Edematous skin is a characteristic of the preterm infant. Abundant body hair, known as lanugo, is another characteristic of the preterm infant. Obvious blood vessels in the skin are characteristic of the preterm infant because the skin is thin and translucent.

During a home visit the nurse obtains information about a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. 1 Lethargy 2 Ambivalence 3 Emotional lability 4 Increased appetite 5 Long periods of sleep

123 Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is associated with depression.

A client is rooming in with her newborn. The nurse sees the infant lying quietly in the bassinet with the eyes open wide. What action should the nurse take in response to the infant's behavior? 1 Brightening the lights in the room 2 Encouraging the mother to talk to her baby 3 Wrapping and then turning the infant to the side 4 Beginning physical and behavioral assessment

2 A quiet, alert state is an optimal time for infant stimulation. Bright lights are disturbing to newborns and may impede mother-infant interaction. Wrapping and then turning the infant to the side is done for the sleeping infant. Physical and behavioral assessments are not the priorities; they may be delayed.

A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13 oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vagina and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain? 1 Full bladder 2 Vaginal hematoma 3 Infected episiotomy 4 Enlarged hemorrhoid

2 A vaginal hematoma caused by fetal head pressure during the birthing process can result in severe pain. Bladder distention causes abdominal, not perineal, discomfort. Although the episiotomy may cause pain, it should not be excruciating; it is too early for an infection to have developed. Although hemorrhoids may cause perineal discomfort, they should not cause the vagina to feel full and heavy.

How should a nurse direct care for a client in the transition phase of the first stage of labor? 1 Decreasing intravenous fluid intake 2 Helping the client maintain control 3 Reducing the client's discomfort with medications 4 Having the client use simple breathing patterns during contractions

2 Helping the client maintain control is the most difficult part of labor, and the client needs encouragement and support to cope. Intravenous fluids may need to be increased because of the increase in metabolism. Medication at this time will depress the newborn and is contraindicated. Breathing patterns at this time should be complex and require a high level of concentration to distract the client.

What potential complication should the nurse anticipate when a pregnant client has premature rupture of the membranes? 1 Dry birth 2 Cord prolapse 3 Prolonged labor 4 Uterine dystocia

2 Premature rupture of the membranes may permit prolapse of the umbilical cord if the fetal head is not engaged. There is continuous secretion of amniotic fluid by the amnion even after rupture of the membranes. Ruptured membranes generally shorten, not lengthen, labor. Ruptured membranes will not cause difficult labor; instead, they usually promote the progression of labor.

A neonate born at 35 weeks' gestation has Apgar scores of 8 and 9. At 4 hours of age the newborn begins to experience respiratory distress, has a below-normal temperature in a warm environment, and has a low blood glucose level. What problem does the nurse suspect? 1 Hypoglycemia 2 Bacterial sepsis 3 Cocaine withdrawal 4 Meconium aspiration

2 Preterm neonates react to infection with respiratory distress and subnormal temperatures. Although hypothermia is one sign of hypoglycemia, the newborn is not exhibiting other signs, such as tremors and lethargy. The data do not indicate that meconium was present at birth. Four hours of age is too early for signs of cocaine drug withdrawal to occur.

Which client is at risk for a postpartum infection? 1 A primipara who gives birth to an infant weighing more than 8.5 lb 2 A woman who required catheterization after voiding less than 75 mL 3 A multipara with a hemoglobin level of 11 g at the time of admission 4 A women who loses at least 350 mL of blood during the birthing process

2 Repeated catheterizations for residual urine increase the chance that bacteria will be introduced and their growth fostered. The size of the newborn does not predispose the mother to postpartum infection. Hemoglobin levels of 11 grams do not reflect the highest risk for infection; a hemoglobin of 11 grams is at the low end of the acceptable range. A loss of 250 to 500 mL of blood is considered acceptable.

A nurse in the newborn nursery observes a yellowish skin coloration in an infant who was delivered in a cesarean birth. What is the immediate nursing action? 1 Notifying the health care provider 2 Ascertaining how many hours ago the neonate was born 3 Taking a heel blood sample and sending it to the laboratory 4 Covering the eyes and placing the neonate under high-intensity ligh

2 The neonate's age is a critical assessment because the development of jaundice before 24 to 48 hours have elapsed since birth may indicate a blood dyscrasia (pathologic jaundice, hyperbilirubinemia) requiring immediate investigation. Jaundice occurring with 48 to 72 hours of birth (physiologic jaundice) is a consequence of the expected breakdown of fetal red blood cells and immaturity of the liver. Unless the jaundice was pathologic (occurring in the first 24 hours of life), this is not necessary. First, the age of the neonate must be ascertained to determine whether this is physiologic or pathologic jaundice; next the nurse should obtain a sample of heel blood to determine the serum bilirubin level. Bilirubin studies should be performed first to determine whether the serum level warrants phototherapy. This therapy requires a health care provider's prescription.

Epidural anesthesia was initiated 30 minutes ago for a client in labor. The nurse determines that the fetus is experiencing late decelerations. List the following nursing actions in order of priority. 1. Increase intravenous fluids. 2. Reposition client on her side. 3. Notify the health care provider if late decelerations persist. 4. Document interventions and related maternal/fetal responses. 5. Reassess the fetal heart rate (FHR) pattern.

21534 Repositioning the client to the side increases uterine blood flow, improves cardiac output, and takes the pressure exerted by the uterus off the vena cava. Increasing the delivery of fluids augments uterine blood flow and improves cardiac output. Reassessing the FHR pattern enables the nurse to determine whether the FHR has returned to a safe level without reflex late decelerations. Persistent late decelerations are a nonreassuring fetal sign; the health care provider should be informed. Documentation of interventions and client responses ensures that information is included in the client's legal clinical record and communicated to other care providers.

A client at 9 weeks' gestation asks the nurse in the prenatal clinic whether she may have chorionic villi sampling (CVS) performed during this visit. What should the nurse keep in mind as the optimal time for CVS while formulating a response? 1 At 8 weeks but no later than 10 weeks 2 At 10 weeks but no later than 12 weeks 3 At 12 weeks but no later than 14 weeks 4 At 14 weeks but no later than 16 weeks

22

A nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Select all that apply. 1 Hypotonia 2 Webbed neck 3 Female sex organs 4 Rocker-bottom feet 5 Widely spaced nipple

235 The broad, webbed neck is an outstanding characteristic of the newborn with Turner syndrome. All infants with Turner syndrome are female because their one sex chromosome is the X chromosome; although they have female sex organs, the organs are underdeveloped and affected individuals are infertile. Widely spaced nipples are also a characteristic of Turner syndrome. Hypotonia is typical of newborns with Down syndrome and trisomy18. Rocker-bottom feet are found in infants with trisomy 18.

A primigravida at 39 weeks' gestation is admitted to the high-risk unit with an acute infection and is to have labor induced. In what sequence should the nurse implement the practitioner's orders? 1. Start oxytocin (Pitocin) 30 units in 1000 mL of D5W per protocol. 2. Initiate monitoring with an electronic fetal/maternal monitor. 3. Call the anesthesia department to evaluate the client for an epidural. 4. Give the client a 2-g loading dose of ampicillin (Omnipen) followed by 1 g every 4 hours.

2413 The client has an infection, so beginning with fetal assessment would be appropriate. The antibiotic is a priority, to be infused before the start of the induction of labor. The oxytocin should be initiated and labor progression monitored before any request for an epidural for anesthesia.

nurse determines that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply. 1 Crackles 2 Cyanosis 3 Wheezing 4 Tachypnea 5 Retractions

245

A nurse is caring for a client with placenta previa who is in labor. What action is most important for the nurse to take? 1 Inserting an internal fetal monitor 2 Performing frequent vaginal examinations 3 Evaluating external blood loss by counting pads 4 Monitoring for a decrease in the height of the fundu

3 Evaluating external blood loss by counting pads will indicate whether bleeding is progressing toward maternal or fetal compromise. Attempting to insert an internal fetal monitor is contraindicated because the placenta will be disturbed; an external fetal monitor should be applied. Vaginal examinations are contraindicated because they may stimulate more bleeding if the placenta is dislodged. The height of the fundus will increase, not decrease, as blood accumulates in the uterus.

A nurse performs Leopold's maneuvers on a pregnant client and documents the following data: soft, firm mass in the fundus; several small parts on the right side; hard, round, movable object in pubic area; and cephalic prominence on right side. Applying these findings, which fetal position does the nurse identify? 1 Left sacroposterior (LSP) 2 Right sacroposterior (RSP) 3 Left occipitoanterior (LOA) 4 Right occipitoanterior (ROA

3 In the LOA position, the small parts are on the right, the smooth back is on the left, and the head is in the pelvis. The LSP position is a breech position, and therefore the fetal head will not be in the pelvic area; the data reveal a hard, round, movable object in the pubic area, which indicates that the fetus is in the vertex position. The RSP position is a breech position, and therefore the fetal head will not be in the pelvic area. In the ROA position, the small parts will be on the left and the smooth back on the right.

The nurse is caring for a preterm infant in the neonatal intensive care unit. What early sign of neonatal sepsis should the nurse report to the health care provider? 1 Flat anterior fontanel 2 Increased temperature 3 Temperature instability 4 Brisk capillary refill time

3 In the neonate, early signs of infection are often subtle and can be indicators of other conditions. There may be temperature instability, respiratory problems, and changes in feeding habits or behavior. Early signs of sepsis in the neonate include full anterior fontanels (not flat) and prolonged capillary refill time (not brisk). Increased temperature or hyperthermia is a rare early sign of sepsis in the neonate.

After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include? 1Taking vital signs every hour 2 Keeping the eye shields on continuously 3 Administering additional fluids every 2 hours 4 Covering the neonate with a lightweight blanke

3 Insensible and intestinal fluid losses are increased during phototherapy; extra fluid prevents dehydration. Taking the vital signs every hour is unnecessary unless a change from the baseline occurs. The eye shields should be removed for feeding and when the infant is being held. The total body needs to be exposed to the light.

A pregnant client with a history of rheumatic heart disease expresses concern about the impending birth. What should the nurse tell her to expect? 1 Induced labor 2 Cesarean birth 3 Regional analgesia 4 Inhalation anesthesia

3 Regional analgesia, such as an epidural, will relieve the stress of pain, and it does not compromise cardiovascular function. Induced labor is often more stressful and painful than spontaneous labor. Major abdominal surgery is performed in clients with cardiac problems only when absolutely necessary. Inhalation anesthesia can compromise cardiovascular function. q

A client who is in labor is admitted 30 hours after her membranes ruptured. For what condition does the nurse anticipate that the client is most at risk? 1 Cord prolapse 2 Placenta previa 3 Chorioamnionitis 4 Abruptio placenta

3 The risk of developing chorioamnionitis (intra-amniotic infection) is increased with prolonged rupture of the membranes; foul-smelling fluid is a sign of infection. A prolapsed cord usually occurs shortly after the membranes rupture, not 1½ days later. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Premature separation of the placenta is unrelated to ruptured membranes.

A client is admitted to the labor and delivery unit for labor augmentation with oxytocin (Pitocin). She is postterm at 40 weeks +3 days and is a gestational diabetic. The cervix is dilated 2 cm and 90% effaced. The health care provider performed an amniotomy to permit internal electronic fetal monitoring. The amniotic fluid is pale yellow and moderate in amount. Immediately after the amniotomy the nurse will assess the fetal heart rate for at least 1 full minute for signs of: 1 Infection 2 Uterine atony 3 Uterine cord prolapse 4 Maternal hypertension

3 The umbilical cord can slip down during after the amniotomy and be compressed between the fetal presenting part and the woman's pelvis. Cord compression is suspected if deep or prolonged variable decelerations occur during contractions or if persistent bradycardia is present after contractions. Uterine atony and maternal hypertension are not assessed with the use of electronic fetal monitoring. It is important to monitor the client for possible infection, but the risk is low immediately after amniotomy; it increases with the interval between membrane rupture and birth.

nurse is caring for a postpartum client with a history of rheumatic heart disease. The nurse plans care for this client with the knowledge that the client should: 1 Increase her oral fluid intake 2 Maintain bedrest for a minimum of 4 days 3 Be out of immediate danger because the stress associated with pregnancy is over 4 Be monitored during the first 48 hours because of the stress on the cardiopulmonary syste

4

While assessing a newborn suspected of having Down syndrome, what does the nurse expect to note? 1 Long, thin fingers 2 Large, protruding ears 3 Hypertonic neck muscles 4 A single line across each pal

4 A single line across the palm of each hand, a characteristic finding in newborns with Down syndrome, is known as a simian crease. Stubby fingers and small ears, not long, slim fingers and large, protruding ears, are commonly found in newborns with Down syndrome. Newborns with Down syndrome have hypotonic, not hypertonic, muscles.

The nurse is planning care for a client with postpartum psychosis. Which priority intervention should the nurse plan to implement? 1 Teaching the client about normal newborn care 2 Ensuring adequate bonding time with the infant 3 Giving the client time and space to express her feelings 4 Referring the client to a psychiatric health care provider as prescribed

4 Assessment and management of postpartum psychosis are beyond the scope of a maternity nurse, and a mother who experiences this condition must be referred to a specialist for comprehensive therapy. Women with signs of postpartum psychosis need immediate medical attention to prevent suicide or infanticide. In light of this psychiatric emergency condition it would not be appropriate to plan bonding time for the client and infant, teach her about normal newborn care, or allow expression of her feelings.

client who recently gave birth is transferred to the postpartum unit by the nurse. What must the nurse do first to avoid a charge of abandonment? 1 Assess the client's condition. 2 Document the client's condition and the transfer. 3 Orient the client to the room and explain unit routines. 4 Report the client's condition to the responsible staff member.

4 Because the nurse is responsible for the client's care until another nurse assumes that responsibility, the nurse should report directly to the client's primary nurse. Making an assessment of the client's condition is not enough. Although documentation is important, it is insufficient. Orienting the client to the room and explaining unit routines is insufficient. Although the nurse should carry out these activities, they may be done after the nurse reports the client's condition to the staff.

A newborn with respiratory distress syndrome (RDS) is receiving continuous positive airway pressure therapy by way of an endotracheal tube. The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. What is the interpretation of these assessment data and the appropriate nursing action? 1 Infants with RDS often have some degree of atelectasis, and there should be no change in treatment. 2 Inspiratory pressure on the ventilator is probably too low and should be increased for adequate ventilation. 3 The endotracheal tube has slipped into the left mainstem bronchus and should be pulled back to ventilate both lungs. 4 The infant may have a pneumothorax, and the practitioner should be called so that corrective therapy can be started immediately.

4 Diminished breath sounds and the PMI in the left axillary line are key signs of a pneumothorax, which can occur when an infant is receiving oxygen by way of positive pressure. Atelectasis is not expected; if it does occur, it requires immediate attention. Low inspiratory pressure is not the cause of the problem. Slippage of the endotracheal tube is not the cause of the problem.

When reviewing the history of a client admitted in preterm labor during her 30th week of gestation, the nurse suspects a risk factor associated with this client's preterm labor. What is this risk factor? 1 Primigravida 2 Android-shaped pelvis 3 Anticonvulsant medication therapy 4 Multiple urinary tract infections

4 Infections, especially urinary tract infections, are a risk factor for preterm labor. The number of pregnancies is not a risk factor for preterm labor. An android-shaped pelvis is more likely to cause dystocia than preterm labor. Clients receiving anticonvulsant medications are not at an increased risk for preterm labor.

woman in the family planning clinic has decided to use the diaphragm for contraception. What should the nurse teach her about using a diaphragm? 1 Completely cover the outside of the diaphragm with spermicidal jelly or cream. 2 Douche within 1 hour of intercourse to enhance the effectiveness of the diaphragm. 3 Correct placement of the diaphragm leaves an inch between the diaphragm and the vaginal wall. 4 Insert the diaphragm before intercourse and leave it in at least 6 hours after intercourse to kill all the sperm

4 It is important to explain that the diaphragm must be inserted before intercourse and left in place for at least 6 hours afterward; removing the diaphragm too early could allow some still-motile sperm to ascend into the uterus. Spermicidal jelly should be applied inside the dome so that it is directly over the cervical os. Douching should not be done at all (especially while the diaphragm is in place, because it will wash away some of the spermicidal jelly); it interferes with the normal flora of the vagina. Correct placement of the diaphragm affords a close fit from vaginal wall to vaginal wall and coverage of the cervix.

A nurse is conducting the admission assessment of a client who is positive for Group B Streptococcus (GBS). Which finding is of most concern to the nurse? 1 Continued bloody show 2 Cervical dilation of 4 cm 3 Contractions every 4 minutes 4 Spontaneous rupture of membranes 3 hours ago

4 Rupture of the membranes before intrapartum treatment of GBS increases the chances that infection will ascend into the uterus. GBS infection is a leading cause of neonatal morbidity and mortality. Continued bloody show, cervical dilation of 4 cm, and contractions every 4 minutes are all normal findings for a client in labor.

What is a nurse's most important concern when caring for a client with a ruptured tubal pregnancy? 1 Infection 2 Hypervolemia 3 Protein deficiency 4 Diminished cardiac outpu

4 The bleeding is causing decreased circulating blood volume and therefore there is a decreased cardiac output. Infection may occur later but is not a problem at this time. There will be hypovolemia, not hypervolemia, because of a decrease in circulating blood volume due to hemorrhage. There are no data to justify the conclusion that the client has a protein deficiency.

A laboring client who is positive for Group B Streptococcus is given an initial dose of ampicillin (Omipen) 2 g at 9 am. According to established guidelines for intrapartum management of this client, the next dose should be: 1 2 g given at 10 am 2 1 g given at 11 am 3 2 g given at noon 4 1 g given at 1 pm

4 The established guidelines for Intrapartum antibiotic prophylaxis (IAP) for a client infected with GBS is an initial dose of 2 g followed by a 1-g dose every 4 hours.

client is to have a vacuum curettage abortion because of fetal demise at 16 weeks' gestation. The health care provider prescribes a dinoprostone (Cervidil) suppository to initiate softening, effacement, and dilation of the cervix (ripening). What should the nurse teach the client about the procedure? 1 "You'll be under general anesthesia for insertion of the suppository." 2 "You'll experience copious bleeding for several hours after the abortion." 3 "A temperature of more than 100° F is common for the first 24 to 48 hours." 4 "After the suppository has been inserted, you should lie flat in bed for 15 minutes."

4Remaining supine for 10 to 15 minutes permits the suppository to remain in place while it melts to body temperature. General anesthesia is unnecessary for the insertion of a dinoprostone suppository. The bleeding that occurs after this type of abortion is usually equivalent to that of a heavy menstrual period. Excessive bleeding or cramping should be reported to the practitioner. A temperature more than 100° F (37.8° C) is a danger sign and the health care provider should be notified.

A nurse is caring for a client in labor. When her cervix is dilated 3 to 4 cm and 60% effaced and the vertex is at -1 station, there is a sudden spurt of dark blood from the vagina. The uterus is irritable on palpation and does not relax fully between contractions. What is the initial nursing action? 1 Transporting the client for a cesarean birth 2 Checking the perineum for rupture of membranes 3 Changing the underpad and positioning the client on her left side 4 Assessing the fetal heart rate, uterine activity, and blood pressur

4The client should be evaluated for signs of abruptio placentae with an assessment for cessation of uterine activity, fetal heart rate decelerations, and falling blood pressure. The status of fetus and mother must be assessed before any other nursing action (i.e., transporting the client for a cesarean birth or changing the underpad and positioning the client on her left side) is taken. Checking the perineum for rupture of membranes is not the priority during this emergency situation.

A client is admitted to the emergency department at 34 weeks' gestation with trauma and significant bleeding from the leg. What is the priority intervention after determining fetal well-being? 1 Obtaining the client's vital signs 2 Offering the client emotional support 3 Placing the client in a left lateral position 4 Drawing the client's blood for laboratory screening

33 The left lateral position will increase placental perfusion, which may be compromised because of the significant bleeding. Obtaining the client's vital signs is not the priority. Although providing emotional support and drawing the client's blood for laboratory screening are both important, preventing fetal and maternal compromise is the priority.

A nurse is assessing a pregnant client during the third trimester. What clinical finding is an expected response in later stages of pregnancy? 1 Tachycardia 2 Dyspnea at rest 3 Progressive dependent edema 4 Shortness of breath on exertion

4 Shortness of breath on exertion is an expected cardiopulmonary adaptation during pregnancy caused by an increased ventricular rate and elevated diaphragm. Tachycardia, progressive dependent edema, and shortness of breath on exertion are each pathologic, signs of impending cardiac decompensation.

During labor the nurse encourages the client to void periodically. The nurse knows that an overdistended urinary bladder during labor can: 1 Predispose the client to uterine hemorrhage after birth 2 Interfere with the assessment of cervical dilation 3 Prevent the diagnosis of cephalopelvic disproportion 4 Delay expulsion of the placenta after the birth of the neonate

1 An overdistended urinary bladder prevents the uterus from contracting after birth; contraction of the uterus constricts blood vessels, preventing hemorrhage. A digital examination to assess vaginal dilation does not require an empty urinary bladder to be accurate. An overdistended urinary bladder may impede descent but does not interfere with this diagnosis. Delaying expulsion of the placenta does not interfere with the third stage of labor.

An adolescent at 10 weeks' gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate? 1 The caloric content will result in too great a weight gain. 2 The ingredients in soft drinks and candy can be teratogenic in early pregnancy. 3 The salt in this diet will contribute to the development of gestational hypertension. 4 The nutritional composition of the diet places her at risk for a low-birthweight infant

4

he mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties? 1 Receding jaw 2 Brain damage 3 Tongue thrust 4 Nasal congestio

3

A woman with an active lifestyle is in her 30th week of pregnancy. Which activity will the nurse discourage? 1 Yoga 2 Swimming 3 Bicycling 4 Leg lifts and sit-ups

4 due to maintaining supine position

A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. What type of infection control precautions should the nurse institute? 1 Enteric 2 Contact 3 Droplet 4 Standar

3

A client who has placenta previa now has started bleeding heavily and is being admitted to the high-risk unit. Why should the nurse place the client in the knee-chest position? 1 It prevents shock. 2 It controls bleeding. 3 It keeps pressure off the cervix. 4 It moves the placenta off the cervix.

1 The knee-chest position shunts blood to the upper body and vital organs. The bleeding will continue, regardless of the client's position. Pressure on the cervix is thought to have no bearing on bleeding episodes. The placenta is implanted, and positioning will not move it off the cervix.

A nurse notes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this small output of urine during the early postpartum period? 1 It may indicate retention of urine with overflow. 2 It may be indicative of beginning glomerulonephritis. 3 This is common because less fluid is excreted after birth. 4 This is common because fluid intake diminishes after birth

1

A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified? 1 Preterm 2 Immature 3 Small for gestational age 4 Appropriate for gestational age

1

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time? 1 Helping the client change her position 2 Informing the client of the problem with the fetus 3 Administering oxygen by mask to the client at 2 L/min 4 Readjusting placement of the fetal monitor on the client's abdomen

1

The nurse is caring for a newborn whose mother was taking an opioid analgesic throughout pregnancy. Which action should the nurse include in the plan of care? 1 Offering small, frequent feedings 2 Keeping the infant exposed in a heated crib 3 Increasing the environmental stimuli 4 Discouraging the mother from giving care

1

s part of the physical assessment, a nurse inspects a newborn for the presence of an umbilical hernia. What infant behavior helps the nurse identify this problem? 1 Crying 2 Inhaling 3 Suckling 4 Sleeping

1 Increased intraabdominal pressure associated with crying, coughing, or straining will cause protrusion of the hernia. Lowering of the diaphragm may increase intraabdominal pressure slightly but not enough to cause protrusion of an umbilical hernia. Suckling and sleeping do not increase intraabdominal pressure.

What is the priority nursing action during a client's second stage of labor? 1 Assessing the perineum for bulging 2 Administering the prescribed analgesia 3 Helping the client pant with each contraction 4 Catheterizing the client before the head reaches 3+ statio

1 A bulging perineum is caused by the pressure of the fetal head against the perineal area and usually signifies imminent birth. Pain medication is not administered this close to the birth; it crosses the placental barrier and can cause respiratory distress in the newborn. During the second stage of labor the client is encouraged to push, not pant, with each contraction. Catheterization may be indicated earlier in labor so uterine contractions are not impeded; voiding will occur spontaneously as the client pushes.

A newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, what is the next nursing action? 1 Feeding the infant 2 Requesting a complete blood count 3 Monitoring the infant for hyperthermia 4 Allowing the infant to rest undisturbed

1 A newborn who experiences a hypothermic episode responds by becoming hypoglycemic; providing calories will increase the blood glucose level. If the hypothermic period is treated adequately, hyperthermia is not expected to develop. The blood count will not change during a transient hypothermic episode. Allowing the infant to rest undisturbed will result in a delay in meeting the newborn's need for an increase in blood glucose.

An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place? 1 The most comfortable position may be assumed. 2 Maintaining a supine position holds the internal electrode in place. 3 Monitoring is more accurate with the client in the side-lying position. 4 The monitor leads may be detached when the client is sitting on the bedpan

1 Because electrodes are placed internally (on the fetal scalp, not on the mother's abdomen), position does not affect the monitor. The side-lying position is recommended because it promotes maternal-fetal circulation. It is not the position but the internal placement of electrodes on the fetal scalp that ensures accurate monitoring. Constant monitoring provides continuous ongoing assessment of fetal status; there is no reason to detach the leads. Although this position does not affect the monitor, it should be discouraged because the pressure of the gravid uterus inhibits venous return, leading to reduced cardiac output.

A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect, including which of the following? Select all that apply. 1 Amenorrhea 2 Breast changes 3 Urinary frequency 4 Abdominal enlargement 5 Positive urine pregnancy test

123 The absence of menstruation (amenorrhea) is a presumptive sign of pregnancy that is recognized at 4 weeks' gestation. Breast changes, related to increased levels of estrogen and progesterone, are a presumptive sign of pregnancy that is recognized at 3 to 4 weeks' gestation. Urinary frequency, related to pressure of the enlarging uterus on the urinary bladder, is a presumptive sign of pregnancy that is recognized at 6 to 12 weeks' gestation. Abdominal enlargement related to the enlarging uterus is a probable sign of pregnancy that is recognized when the enlarging uterus rises out of the pelvis at 14 to 16 weeks' gestation. A positive urine pregnancy test result, indicating an increase in human chorionic gonadotropin, is a probable sign of pregnancy. Sensitive blood tests can detect this hormone within 6 to 12 days of conception, and urine tests can detect it 26 days after conception.

ypical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply. 1 Tremors 2 Dehydration 3 Hyperactivity 4 Muscle hypotonicity 5 Prolonged sleep periods

13 Opioid dependence in the newborn is physiological; as the drug is cleared from the body, signs of drug withdrawal become evident. Tremors are a typical sign of cerebral irritability. Hyperactivity is a typical sign of cerebral irritability. Dehydration is a result of inadequate feeding, not a direct result of opioid withdrawal. Muscle hypertonicity, not hypotonicity, occurs with opioid withdrawal. Signs of opioid withdrawal include excessive activity and sleep disturbances.

As a client who has just given birth examines her newborn, she notes a nevus vasculosus on her infant's mid thigh and becomes upset. How should the nurse respond? 1 "These areas usually spread and then regress." 2 "The mark is superficial and will fade in a few days." 3 "The mark is permanent, but it can be covered with clothes." 4 "The area may require surgical removal when your baby is a little older."

1Spreading and then regressing is the usual pattern that a nevus vasculosus, which involves the dermal and subdermal layers, follows. Saying that the area will be covered by clothes gives little assurance. Surgical removal is not recommended.

contraction stress test (CST) is performed on a client at 40 weeks' gestation. The findings are interpreted as negative. What does the nurse conclude from this interpretation? 1 Testing will be repeated in 24 hours because the results indicate hyperstimulation. 2 There will be weekly retesting because, at this time, the fetus has oxygen reserves. 3 Emergency birth will be considered because the fetal heart rate has early decelerations with uterine contractions. 4 Induction of labor will be performed because fetal heart rate accelerations with movement is indicative of a false result.

2 A negative test result implies that placental support is adequate; it is associated with a low fetal death rate within 1 week. A negative test result does not indicate hyperstimulation. This is a negative test result; if there were persistent late decelerations with contractions, the test would be positive and intervention would be required. Fetal heart rate accelerations with movement are reassuring; an expeditious birth is not indicated.

A nurse who is caring for a client in labor uses Nitrazine paper to test the pH of the client's leaking vaginal fluid. What color will the Nitrazine paper turn if the leakage is amniotic fluid? 1 Red 2 Blue 3 Purple 4 Yellow

2 Amniotic fluid is alkaline (pH of 7 to 7.50) and turns Nitrazine paper blue. Amniotic fluid does not change Nitrazine paper red. Amniotic fluid does not change Nitrazine paper purple. Yellow in the Nitrazine paper usually indicates intact membranes.

A pregnant woman arrives in the emergency department, crying, "My baby is coming!" The nurse determines that the fetus's head is crowning and birth is imminent. What should the nurse do to support the baby's head? 1 Apply suprapubic pressure. 2 Distribute fingers evenly around the head. 3 Place a hand firmly against the mother's perineum. 4 Maintain firm pressure against the anterior fontane

2 Distributing the fingers evenly around the head will help prevent a rapid change in intracranial pressure after the birth of the head. Applying suprapubic pressure will not aid in birth of the head; it is used when shoulder dystocia occurs during the birth process. Placing a hand firmly against the mother's perineum could interfere with the birth and injure the fetus. Maintaining firm pressure against the anterior fontanel could injure the fetus; gentle pressure over the entire head is the safest action.

A community health nurse visits an infant who was born at home 24 hours ago. While assessing the infant the nurse identifies slight jaundice of the face and trunk. What should the nurse do next? 1 Plan for immediate admission to the hospital. 2 Obtain a stat prescription for a bilirubin level. 3 Document this expected finding in the infant's record. 4 Arrange for the infant to have phototherapy in the home

2 Jaundice that appears within 24 hours of birth may be indicative of a pathological process; if the bilirubin level is high, intervention is required. Jaundice is not an indication for admission unless accompanied by a very high serum bilirubin level. Physiologic jaundice does not appear until 72 hours after birth; this observation in the 24 hours after birth indicates pathologic hyperbilirubinemia. The infant may require phototherapy after further assessment, but this is not the first action.

A client tells a nurse that she does not want an episiotomy and would rather tear naturally. What information should be offered regarding each of these birthing methods? 1 Lacerations are more painful than an episiotomy. 2 Lacerations are easier to repair than an episiotomy. 3 An episiotomy causes less posterior trauma than lacerations. 4 An episiotomy is preferred over lacerations, according to evidence-based practice.

2 Lacerations require less suture time and cause less perineal trauma, which can have lifelong implications such as rectal-vaginal fistulas. Lacerations are less painful than an episiotomy and tend to heal more quickly. An episiotomy causes more posterior trauma than lacerations. Evidence indicates that a policy of routine episiotomy results in more perineal trauma, more suturing time, and more complications than lacerations.

A new mother asks a nurse how to care for her baby's umbilical cord stump. What should the nurse teach the mother? 1 Expect a moderate amount of drainage. 2 Provide sponge baths until the stump falls off. 3 Keep the area moist with sterile normal saline. 4 Cover the site with a small sterile dressing twice a day

2 The infant is given sponge baths instead of being immersed in a tub of water because the moisture will retard drying of the cord stump and will delay its falling off. Drainage is indicative of infection; the cord stump should be dry. Moisture slows the drying process and promotes bacterial growth. Keeping the cord stump covered delays drying.

A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by: 1 Oxidization of fatty acids 2 Shivering when chilled 3 Metabolism of brown fat 4 Increased muscular activity

3

A client is receiving an intravenous piggyback infusion of oxytocin (Pitocin) to augment labor. The nurse identifies three contractions lasting 80 to 90 seconds less than 2 minutes apart. A specific protocol is followed in response to this observation. List in order of priority the nursing actions that should be taken. 1. Check the fetal heart rate (FHR). 2. Stop the piggyback infusion. 3. Notify the health care provider. 4. Administer oxygen by way of facemask. 5. Document the responses of the client and fetus. 6. Determine whether the contractions have diminished.

236145 When tetanic contractions occur, the nurse should first stop the oxytocin infusion; this should relax the uterus and prevent uterine tetany and rupture. The FHR should be checked to determine the effect of the tetanic contractions on the fetus. After the FHR has been assessed, the maternal response to the interruption of the infusion should be assessed. Once these measures have been implemented, the primary care giver should be notified. Fetal well-being will improve when oxygen is administered. After emergency measures have been taken, the client's and fetus's responses should be documented.

A client gives birth to a full-term newborn with an 8/9 Apgar score. Place the initial nursing care actions in order of their priority. 1. Perform physical assessment. 2. Place skin to skin. 3. Instill antibiotic prophylaxis and administer vitamin K. 4. Apply identification band to mother and infant.

2413 Hypothermia can cause many complications for a newborn, and therefore it should be avoided by initiating skin-to-skin contact Placing the identification band on the mother and infant is a safety measure that should be performed after thermoregulation needs are met. A physical assessment should be performed next to identify any additional nursing interventions that may be needed in light of physical assessment findings. Instillation of the antibiotic and administration of vitamin K should be completed within an hour of birth or per facility policy.

A health care provider orders a contraction stress test (CST) for a client whose nonstress test (NST) was nonreactive. Which maternal complications should prompt the nurse to question the order? Select all that apply. 1 Hypertension 2 Preterm labor 3 Drug addiction 4 Incompetent cervix 5 Premature rupture of membrane

245 The CST could trigger a preterm birth in a woman who is in preterm labor or has a history of preterm births. The CST could trigger a preterm birth in a woman who has had the Shirodkar procedure for an incompetent cervical os because it would exert pressure on the sutures and could cause them to rupture. The CST could trigger a preterm birth in a woman whose membranes have ruptured prematurely; the woman is at risk for a preterm birth already. The CST is indicated to assess the influence of hypertension on the placental circulation and determine the response of the compromised fetus to labor.

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor? 1 Heavy vaginal bleeding 2 Fetal heart rate irregularities 3 Greenish-tinged amniotic fluid 4 Severe back pain with contractions

3 Greenish amniotic fluid is common in a breech presentation because the contracting uterus exerts pressure on the fetus's lower colon, forcing the expulsion of meconium. Mild bloody show is expected; a heavier flow is a deviation from the expected response and not a common finding with breech presentations. Fetal heart rate irregularities are not specific to a breech presentation. Severe back pain is more likely to occur when the fetus is in a cephalic presentation and the occiput is in the posterior position.

A nurse withholds methylergonovine maleate (Methergine) from a postpartum client. What clinical finding supports the withholding of the medication? 1 Urine output of 50 mL/hr 2 Third-degree perineal laceration 3 Blood pressure of 160/90 mm Hg 4 Respiratory rate of 12 breaths/min

3 Methylergonovine maleate can cause hypertension and should not be given to a client with an increased blood pressure. Urine output of 50 mL/hr is an expected finding in a healthy adult. Perineal lacerations are not related to methylergonovine maleate (Methergine) use. Methylergonovine maleate does not affect respiration.

A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client? 1 Fewer contractions 2 Depressed respirations 3 Decreased blood pressure 4 Accumulated respiratory secretions

3 Mild reactions, including vertigo, dizziness, and hypotension, occur because of vasodilation resulting from direct action of these medications on the mother's pelvic blood vessels. The progress of labor is not affected by a local anesthetic administered during the second stage of labor. A local anesthetic does not affect the respiratory center in the central nervous system. Accumulated respiratory secretions are not caused by a local anesthetic administered during the second stage of labor.

A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse tell the client to do? 1 Push forcefully. 2 Turn to the left side. 3 Use the pant-breathing pattern. 4 Assume the knee-chest position

3 Panting will slow the process so the nurse can support the head as it is born. Pushing will speed the birth, which could result in injury to both mother and fetus. Turning the mother on her left side will have no effect on the progress of the second stage of labor, and it is difficult to accomplish when the fetal head is crowning. Having the mother assume the knee-chest position will have no effect on the progress of the second stage of labor, and it is difficult to accomplish when the fetal head is crowning.

A nurse assesses a primigravida who has been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin (Pitocin) infusion is prescribed. What is the priority nursing intervention at this time? 1 Checking cervical dilation every hour 2 Keeping the labor environment dark and quiet 3 Infusing oxytocin by piggybacking into the primary line 4 Positioning the client on the left side throughout the infusion

3 Piggybacking the oxytocin (Pitocin) infusion allows it to be discontinued, if necessary, while permitting the vein to remain open by way of the primary IV. Cervical dilation is checked when there is believed to be a change, not on a regular basis. Unless specifically requested by the client, there is no reason to maintain a dark, quiet labor environment. Although positioning the client on her left side is recommended, it is not the primary concern at this time; there are no data to indicate maternal hypotension.

A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a course on several tests during pregnancy. Place the tests in the order in which they should be performed during pregnancy. 1. Fetal movement test 2. Serum glucose for gestational diabetes 3. Sickle cell screening 4. Group B Streptococcus culture 5. α-Fetoprotein (AFP) testing for neural tube defect

35214 Sickle cell screening, particularly for black women, should be done on the initial visit. AFP testing for neural tube defects should be done between 14 and 16 weeks. Serum glucose testing for gestational diabetes should be done between 26 and 28 weeks. Fetal movement tests may be started at 28 weeks' gestation because the fetus' pattern of movement becomes stabilized at this time. Group B Streptococcus culture should be done between 36 and 38 weeks.

A nurse is estimating a newborn's gestational age. What parameters should the nurse assess? Select all that apply. 1 Weight 2 Length 3 Breast size 4 Tonic-neck reflex 5 Genital developmen

35The presence of breast buds and the development of breast tissue occur at a specific time during gestation and are reliable indicators of gestational age, as is the development of genitalia, which also occurs at a specific time during gestation. Weight and length, which are influenced by both genetics and prenatal stresses, are not accurate indicators of gestational age. The tonic-neck reflex is a primitive reflex found in newborns that disappears at 6 months, but it is not a component of the gestational age assessment.

A multipara client with a history of gestational hypertension and previous history of abruption is in the transition phase of labor. Suddenly the electronic fetal monitor shows fetal bradycardia and a change is seen in the contour of client's abdomen. What is the nurse's first priority? 1 Checking the client's vital signs 2 Placing the client on her left side 3 Immediately placing an internal scalp electrode on the fetus 4 Alerting others about the need for immediate cesarean delivery

4 Another nurse should be asked to get the operating room staff, obstetrician, anesthesiologist, neonatal team ready; the client's nurse should monitor vital signs, watch for signs of hypotension and tachycardia, insert an indwelling catheter, and stay as calm as possible while explaining to client that the staff are working together to bring about a safe outcome. The client is exhibiting signs of uterine rupture. An emergency cesarean birth is the priority. Vital signs may be checked immediately after another nurse has been asked to bring the team together. Placing an internal fetal monitor is a poor use of valuable time and requires a prescription from the health care provider. Client history and fetal bradycardia, and change of abdominal contour indicates uterine rupture. q

A newborn is circumcised before discharge from the hospital. What should immediate postoperative care include? 1 Keeping the infant NPO for 4 hours to prevent vomiting 2 Encouraging the intake of alkaline fluids to reduce urine acidity 3 Changing the dressing using dry, sterile gauze to maintain cleanliness 4 Encouraging the mother to cuddle her baby to provide emotional support

4 Cuddling is comforting for the mother and baby and provides an opportunity to teach the mother how to take care of the circumcision. There is no contraindication to feeding the infant after the circumcision; nutrition may be withheld before, not after, the procedure. Providing alkaline fluids is inappropriate and could lead to fluid and electrolyte imbalance. Removal of dry gauze will cause bleeding; sterile petrolatum gauze is used and replaced with each diaper change.

A nurse in the neonatal intensive care unit is caring for a preterm newborn with respiratory distress syndrome (RDS). What clinical finding does the nurse expect? 1 Inspiratory stridor 2 Heart rate of 100 beats/min 3 Arterial blood pH of 7.35 4 Diminished breath sounds

4 Diminished breath sounds are consistent with RDS because of atelectasis and underinflation of alveoli resulting from decreased surfactant in immature lungs. Neonates with respiratory distress syndrome (RDS) have expiratory, not inspiratory, stridor. Neonates with RDS are more likely to have tachycardia. A pH of 7.35 to 7.45 is within the expected range for healthy newborns; neonates with RDS tend to have a decreased pH, which is indicative of respiratory or mixed acidosis.

What is the priority nursing care after an amniocentesis? 1 Giving perineal care after the procedure 2 Encouraging lots of fluids every hour 3 Changing the abdominal dressing 4 Monitoring for signs of uterine contractions

4 It is possible that stimulation of the uterus resulting from the amniocentesis will cause uterine contractions. Perineal care is not necessary because an amniocentesis is not done by way of the vagina. Encouraging fluids every hour is irrelevant because the amount of amniotic fluid is not influenced by fluid ingestion. Changing the abdominal dressing is not necessary because the needlestick site seals immediately.

A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm3. What is the next nursing action? 1 Checking with the nurse manager to see whether the client may go home 2 Reassessing the client for signs of infection by taking her vital signs 3 Delaying the client's discharge until the practitioner has conducted a complete examination 4 Placing the report in the client's record because this is an expected postpartum finding

4 Leukocytosis (15,000-20,000/mm3 WBC) typically occurs during the postpartum period as a compensatory defense mechanism. There is no need for further intervention, because the client is exhibiting an expected postpartum leukocytosis.

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required? 1 "We'll have to start serial casting right away." 2 "The casts will have to be changed every week." 3 "The baby may have to have surgery if the problem's not fixed in a few months." 4 "We'll have to have the baby fitted with prosthetic devices before he'll be able to walk.

4 Most children with bilateral clubfeet are eventually able to walk without much difficulty. Prosthetic devices generally are not indicated. Serial casting with cast changes every week is usually successful. If serial casting is not effective, surgical intervention may be necessary.

An expectant couple asks the nurse about the cause of low back pain during labor. The nurse replies that this pain occurs most often when the fetus is positioned: 1 Breech 2 Transverse 3 Occiput anterior 4 Occiput posterio

4Persistent occiput posterior positioning causes intense back pain, the result of fetal compression of the sacral nerves. The breech position is not associated with back pain. The transverse position is not associated with back pain. Occiput anterior, the most common fetal position, generally does not cause back pain.

newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate? 1. 2 2. 3 3 .4 4. 5

A heart rate of less than 100 beats/min = 1; slow and irregular respirations = 1; grimaces in response to suctioning = 1; flaccid muscle tone = 0; and cyanosis = 0. This infant's Apgar score is 3. A score of 2 is too low. A score of 4 is too high, as is a score of 5.

A nurse is assessing a pregnant 16-year-old client. What factors that may affect the outcome of the pregnancy should the nurse consider? Select all that apply. 1 Tendency to abuse drugs 2 Inappropriate dietary choices 3 Immature reproductive system 4 Underdeveloped musculoskeletal system 5 Undeveloped secondary sex characteristics

234 Adolescents are peer oriented and tend to eat fast foods with their friends; the diet is generally high in fats and carbohydrates and deficient in protein, calcium, fruits, and vegetables. At 16 years, development of the reproductive organs is incomplete: Full growth of the vagina, uterus, ovaries, and uterine tubes does not occur until 20 years of age. Musculoskeletal growth is generally not complete until early adulthood. Although adolescents may experiment with drugs, it is a judgmental belief that they all abuse drugs. Secondary sex characteristics appear early and are complete by the end of puberty; if the adolescent is pregnant, she has completed puberty.

A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? 1 In utero through the placenta 2 In the postpartum period through breast milk 3 During birth through contact with the maternal vagina 4 After the birth through a blood transfusion given to the mother

1

A newborn whose mother has type 1 diabetes has been receiving a continuous infusion of fluids with glucose. What should the nurse plan to do when there is an order to discontinue the infusion? 1 Gradually decrease the rate. 2 Observe for metabolic alkalosis. 3 Withhold oral feedings for several hours. 4 Perform glucometer readings every hour.

1 A gradual decrease in the administration of IV glucose is necessary to prevent a hypoglycemic reaction. Metabolic alkalosis will not occur with discontinuation of the glucose; it occurs with excessive amounts of bicarbonate. Withholding oral feedings when an intravenous infusion of glucose is discontinued may result in hypoglycemia. It is not necessary to perform frequent glucometer readings because hypoglycemia is unlikely to occur when the glucose infusion rate is decreased gradually and feedings are instituted.

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. During her intake assessment, she tells the nurse that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action? 1 Assessing maternal vital signs 2 Planning for an emergency birth 3 Administering oxygen by way of nasal cannula 4 Preparing for fetal scalp blood sampling

1 A prolonged period after the rupture of membranes and fetal tachycardia indicate the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations. Planning for an emergency birth is premature unless the fetal status deteriorates and intrauterine resuscitation efforts fail. Administration of oxygen should be done with high flow oxygen via non-rebreather if there is a non-reassuring assessment of the external monitoring, which is not demonstrated in this scenario. Fetal scalp blood testing may be done after additional data are collected and the cause of the tachycardia is determined.

The husband of a client in labor asks about an indentation on his wife's abdomen. The nurse explains that it is a retraction ring (Bandl's ring). What is the next nursing action? 1 Explaining to him what it means and notify the practitioner 2 Advising him that his wife is starting to enter the second stage of labor 3 Informing him that it is a sign that the fetus is descending in the birth canal 4 Telling him that this indentation is expected and that it reflects the strength of the contractions

1 Bandl's ring is a pathological retraction ring, a sign of impending uterine rupture. There is a ridge around the uterus at the junction of the upper and lower uterine segments. The upper segment is distended and thin and the lower segment is thick. Although the ring may occur during the second stage of labor, it is not a sign that the second stage of labor is beginning. A retraction ring impedes the progress of labor; it is associated with premature rupture of the membranes, dystocia, and prolonged labor. A retraction ring is pathological, not expected.

A client at 35 weeks' gestation is admitted to the birthing unit with a small amount of bright-red vaginal bleeding without contractions. What should the nurse do after placing the client in bed? 1 Check fetal heart tones. 2 Obtain an amniotomy pack. 3 Take the client's vital signs. 4 Perform a vaginal examination.

1 Because vaginal bleeding is present, the priority nursing action is ascertaining whether a viable fetus is present. Obtaining an amniotomy pack is contraindicated; bright-red bleeding is suggestive of placenta previa. Taking the client's vital signs is the next nursing action after fetal well-being has been determined. Performing a vaginal examination is contraindicated; bright-red bleeding is suggestive of placenta previa.

A client with class I heart disease is at 34 weeks' gestation. What problem should the nurse anticipate now that the client is in her third trimester? 1 Dyspnea at rest 2 Vasovagal syncope 3 Progressive dependent edema 4 Shortness of breath on exertion

1 Dyspnea at rest is associated with cardiopulmonary disorders and may be a sign of impending decompensation. Vasovagal syncope is an expected physiological change. The client with heart disease is more likely to have exertional syncope. Dependent edema commonly occurs in women with uncomplicated pregnancies as they progress toward term. The client with heart disease is more likely to experience generalized edema. In the third trimester, clients with uncomplicated pregnancies complain of shortness of breath on exertion; this is caused by compression of the diaphragm by the enlarging uterus.

n infant in the newborn nursery has cyanosis of the hands and feet and circumoral pallor when crying. What should the nurse consider, in light of these assessment findings? 1 Notifying the health care provider, because circumoral pallor may signal a cardiac problem 2 Taking no specific action, because both signs are expected in a newborn until 2 weeks of age 3 Taking no specific action, because circumoral pallor is a common finding for the first 72 to 96 hours 4 Notifying the health care provider, because cyanosis usually accompanies increased intracranial pressure

1 Cardiac pathology can be detected at an early age, and circumoral pallor may be a sign. Circumoral pallor is not expected in a healthy newborn, or in a person of any age. Cyanosis does not indicate increased intracranial pressure.

An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action? 1 Assessing the infant for signs of pneumonia 2 Securing a prescription for allergy testing of the infant 3 Bathing the infant's eyes with a tepid boric acid solution 4 Teaching the mother to wash her hands before touching the infant

1 Chlamydia trachomatis is associated with the development of pneumonia in the newborn. Purulent conjunctivitis at this time suggests a Chlamydia infection, not an allergic response. Boric acid solution will not solve this problem; a prescribed antibiotic is required. Teaching the mother to wash her hands before touching the infant would be done eventually; however, the priority is assessing the infant for signs of pneumonia.

Assessment of a newborn reveals congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy? 1 Rubella 2 Herpes virus type 2 3 Toxoplasmosis gondii 4 Chlamydia trachomatis

1 Congenital rubella (German measles) syndrome results in abnormalities that vary, depending on the gestational age of the fetus when the maternal infection was contracted; the most severe results occur if the mother was infected during the first trimester, when organogenesis is taking place. Neonatal signs of herpes virus type 2 include fever, coryza, tachycardia, and hemorrhage. Except for microcephaly, the assessments noted by the nurse are not caused by the toxoplasmosis protozoa; this problem is associated with growth retardation, hydrocephalus, chorioretinitis, thrombocytopenia, jaundice, and fever. A chlamydial infection causes neonatal conjunctivitis and pneumonia.

A client with abruptio placentae has an emergency cesarean birth. Subsequently the nurse notes bloody urine in the indwelling catheter collection bag. What impending problem does the nurse suspect? 1 Incisional nick in the bladder 2 Urinary infection from the catheter 3 Uterine relaxation with increased lochia 4 Disseminated intravascular coagulopathy

1 During an emergency cesarean birth the urinary bladder may be nicked during attempts to reach the uterus. Bleeding associated with a urinary tract infection is unlikely to develop so soon after a birth. Lochia is expelled from the vagina, not the bladder. With dissociated intravascular coagulopathy there would be bleeding from other sites, such as the incision and the IV, not just the bladder.

On reporting to the labor and delivery area a primipara indicates to the nurse that her contractions are occurring every 5 minutes. Upon further inquiry the nurse learns that the client has not attended any childbirth classes, and a cervical assessment reveals that she is in labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques? 1 During the latent phase of the first stage of labor 2 During the active phase of the first stage of labor 3 During the active phase of the second stage of labor 4 During the transition phase of the first stage of labor

1 During the latent phase of the first stage of labor the client is excited and open to learning. The contractions are not as strong as they are going to be, so the client has time between contractions to absorb the nurse's teaching. Contractions are more frequent and stronger in the active phase of the first stage. The increased frequency decreases the client's ability to absorb information. During the active phase of the second stage of labor the client will be bearing down to expel the fetus and simple breathing techniques are not appropriate. During the transition phase of the first stage of labor the contractions are at their maximum intensity, which inhibits the client's ability to listen.

The gravida 1 now para 1 woman delivered a 7-lb 6-oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks the baby be picked up so she can take a nap. What behavior is the new mother demonstrating? 1 Taking-in 2 Letting-go 3 Taking-hold 4 Bonding failure

1 During the taking-in period the mother focuses on her needs rather than the baby's. During this period the mother needs to be "mothered" so she can assume the role of mother. The letting-go period is when the mother wants to take control and "mother" the infant. The taking-hold period is when the mother is anxious to learn about the infant and how to care for it. This mother shows positive behaviors, including smiling, kissing, and holding. There is no evidence of a failure to bond.

During a male newborn's first encounter with his mother the nurse encourages her to undress him. The mother strokes him with her whole hand and while looking at him intently says, "He feels so velvety, and he is going to be just as good looking as his daddy." The baby is alert and responsive while gazing at his mother. What is the nurse's assessment of this first mother-infant encounter? 1 Early parenting behavior 2 Neonatal attachment behavior 3 Newborn consummatory behavior 4 Overprotective parenting behavio

1 Early parenting behavior is typified by the touch that shows maternal bonding; attachment is manifested when the newborn is compared to the father. Attachment behaviors in the neonate consist of grasping and sucking the nipple. Consummatory behaviors in the newborn are coordinated sucking and swallowing. The mother's behavior does not demonstrate overprotection.

The nurse is providing care to a multiparous client in active labor. The client is requesting something for the pain. What is the nurse's next action? 1 Examining the client's cervix for dilation and effacement 2 Determining the client's options by assessing the prescriptions in the chart 3 Asking her whether she prefers an epidural or something in her intravenous line 4 Evaluating the fetal monitoring strip to determine the frequency and duration of contractions

1 Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia. Assessment is the first step of the nursing process. Options for pain management would be determined after dilation has been assessed. The client may be asked about her preferred method of analgesia, but that should be done after her degree of dilation has been determined. The stem of the question indicated that the client is in active labor; information on the fetal monitoring strip regarding contractions will not add to the assessment data.

A preterm newborn is placed in the neonatal intensive care unit. What is the first concern that the nurse anticipates for this infant's mother? 1 Fear of touching the infant 2 Failure to bond with the infant 3 Inability to provide breast milk for the infant 4 Anxiety that the father may not accept the infant

1 Fear stems from the size and frailty of the newborn and the overwhelming environment of the intensive care area; parents should be encouraged to touch and handle their infants when possible. Bonding is possible and can be enhanced when the fear of touching has been overcome. The breasts can be pumped and the milk administered by way of gavage feedings. Although whether the father will accept the infant may be a matter for a concern, it is not the most common initial concern.

Several hours after delivery, a new mother expresses ambivalence about her infant. How will the nurse promote bonding between this mother and her newborn? 1 Having the mother feed the infant 2 Removing the infant from the mother's arms if it cries 3 Positioning the infant so its head rests on the mother's shoulder 4 Encouraging the mother to sleep for 4 to 6 hours before interacting with the infan

1 Feeding the infant promotes bonding through physical interaction, and positioning the infant in a face-to-face position facilitates eye contact. Removing the infant decreases the pair's time together. Positioning the infant on the mother's shoulder prevents the face-to-face contact that promotes bonding. It is important to have the parent and infant interact as soon as possible after birth to promote bonding.

A primigravida is admitted to the emergency department with a sharp, shooting pain in the lower abdomen and vaginal spotting. A ruptured tubal pregnancy is diagnosed. During what week of gestation does this condition most commonly occur? 1 6th 2 12th 3 16th 4 18th

1 In the sixth week the fallopian tube can no longer expand to accommodate the size of the growing embryo. A tubal pregnancy cannot advance to the 12th, 16th, or 18th week because the tube cannot expand to accommodate the growing fetus.

A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose mother: 1 Has type 1 diabetes 2 Has been hypertensive during pregnancy 3 Was preeclamptic during the labor and birth 4 Was a previous abuser of heroin and other opioid

1 Infants of diabetic mothers are at risk for respiratory distress syndrome as a result of delayed synthesis of surfactant caused by a high serum level of insulin. The infant of a mother with hypertension may be small for gestational age but not necessarily preterm and at risk for RDS. Preeclampsia does not predispose the full-term newborn to the development of RDS. The mother's use of heroin or other opioids does not necessarily predispose the newborn to RDS.

A client with type 1 diabetes is being counseled on what to expect during her recently confirmed pregnancy. Which statement indicates that the client needs further education? 1 "I can expect that my insulin requirements will be less." 2 "My blood glucose readings may be lower during my first trimester." 3 "I may need extra insulin during the second half of my pregnancy." 4 "Drinking more water will decrease my risk of a urinary tract infection.

1 Insulin requirements during pregnancy will increase during the second and third trimesters. The other options (lower insulin requirements, lower blood glucose readings in the third trimester, reducing the risk of urinary tract infection by drinking more water) are true statements that do not indicate a need for further education.

Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiologic jaundice, a benign condition, caused by: 1 Immature liver function 2 An inability to synthesize bile 3 An increased maternal hemoglobin level 4 A high hemoglobin and low hematocrit level

1 Jaundice occurs because of the expected physiologic breakdown of fetal red blood cells and the inability of the newborn's immature liver to conjugate the resulting bilirubin. Breastfed neonates are more prone to physiologic jaundice because of diminished calorie and fluid intake in the 3 days before milk production reaches normal volume. Conjugation and excretion, not synthesis of bile, are compromised because of the immature liver. The mother's hemoglobin level is unrelated to the newborn's; the mother and the fetus had separate circulations. Newborns usually have high hemoglobin and high hematocrit levels.

A client at 34 weeks' gestation is receiving terbutaline (Brethine) subcutaneously. Her contractions increase to every 5 minutes, and her cervix dilates to 4 cm. The tocolytic is discontinued. What is the priority nursing care during this time? 1 Promoting maternal-fetal well-being during labor 2 Reducing the anxiety associated with preterm labor 3 Supporting communication between the client and her partner 4 Assisting the client and her partner with the breathing techniques needed as labor progresses

1 Labor is continuing, and the promotion of the well-being of the client and fetus is the priority nursing care during this period. Reducing the anxiety associated with preterm labor, supporting communication between the client and her partner, and assisting the client and her partner with breathing techniques each address one aspect of this client's needs; the priority is maternal/fetal well-being.

A parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" What information about a newborn should the nurse consider before replying in language that the parent will understand? 1 Gastric acidity is low and does not provide bacteriostatic protection. 2 Absence of hydrochloric acid renders the stomach vulnerable to infection. 3 Infants are almost completely lacking in immunity and require sterile fluids. 4 Escherichia coli, a bacterium that is found in the stomach, does not act on milk.

1 Low gastric acidity in newborns predisposes them to gastrointestinal infections, so it is necessary to clean bottles with soap and water. Hydrochloric acid is present in the gastric juices but not in quantities sufficient to protect the infant. The infant is born with passive immunity from maternal antibodies. Escherichia coli is an intestinal bacterium; it is not found in the stomach.

During labor a client who is receiving epidural anesthesia has an episode of severe nausea, and her skin becomes pale and clammy. What is the immediate nursing action? 1 Elevating the legs 2 Notifying the practitioner 3 Checking for vaginal bleeding 4 Monitoring the frequency of contractions

1 Maternal hypotension is a common complication of epidural anesthesia, and nausea is one of the first clues that it has occurred; elevating the lower extremities restores blood volume to the central circulation. If signs and symptoms do not abate after elevation of the legs, the practitioner should be notified. Checking for vaginal bleeding and monitoring the frequency of contractions are not specific observations associated with the administration of anesthesia; they are each part of the general nursing care during labor.

A nurse is caring for a preterm infant with necrotizing enterocolitis (NEC). What nursing intervention is most important for this infant? 1 Measuring abdominal girth frequently 2 Diluting the formula mixture as ordered 3 Administering oxygen before the gastric feeding 4 Using half-strength formula for gavage feeding

1 NEC is marked by prolonged gastric emptying; an increase in abdominal girth of more than 1 cm in 4 hours is significant and requires immediate intervention. Formula feeding is stopped and parenteral fluids, usually total parenteral nutrition (TPN), are started instead. Administering oxygen before the gastric feeding will have no therapeutic value for an infant with NEC.

A neonate born at 36 weeks' gestation, weighing 2043 g (4 lb 8 oz), is placed under a radiant warmer. An infusion of D10% 0.2 NS is running through an umbilical vein catheter at a rate of 12 mL/hr. Why is it important for the nurse to check the neonate's voidings for specific gravity? 1 Infants under open radiant warmers are at risk for dehydration. 2 This infusion rate is inadequate to meet a preterm infant's fluid needs. 3 Infants are unable to produce adequate amounts of urine at this gestational age. 4 Renal dysfunction is the complication that most frequently affects preterm infants.

1 Open radiant warmers cause excessive fluid loss without electrolyte loss. This infusion rate, based on a rate of 100 mL/kg/day for maintenance fluid and an additional 88 mL/kg/day for fluid loss caused by the radiant warmer, is appropriate for an infant of this size. An infant at 36 weeks' gestation is able to produce sufficient quantities of urine but is unable to concentrate urine effectively. Respiratory distress syndrome is the most frequent complication in a preterm infant.

A preterm neonate is receiving oxygen by way of an overhead hood. What should the nurse do to protect the infant under the oxygen hood? 1 Put a hat on the infant's head to avoid hypothermia. 2 Offer fluid every 15 minutes to prevent dehydration. 3 Keep the oxygen concentration consistent to limit respiratory distress. 4 Remove the infant from the hood every 15 minutes to provide stimulation

1 Oxygen has a cooling effect, and the infant should be kept warm so metabolic activity and oxygen demands are not increased. Offering fluid every 15 minutes may produce fluid overload, which could in turn result in increased cardiac output; this is an undesirable outcome, especially for an infant with respiratory distress. Oxygen concentration is determined from blood gas levels and is changed accordingly. Removing the infant from the hood every 15 minutes will tire the infant and increase the need for oxygen.

A client at 38 weeks' gestation is admitted for induction of labor. Her membranes ruptured 12 hours ago. There are no other signs of labor. Which medication does the nurse anticipate will be prescribed? 1 Oxytocin (Pitocin) 2 Estrogen (Premarin) 3 Ergonovine (Ergotrate) 4 Progesterone (Prometrium

1 Oxytocin (Pitocin) is a small-polypeptide hormone synthesized in the hypothalamus and secreted from the neurohypophysis (posterior pituitary gland) during parturition or suckling; it promotes powerful uterine contractions and is therefore used to induce labor. Estrogen (Premarin) suppresses follicle-stimulating and luteinizing hormones, thereby helping maintain a pregnancy. Ergonovine (Ergotrate) can induce sustained contractions, which is contraindicated during labor; it may be prescribed in the postpartum period to promote or maintain a contracted uterus. Progesterone (Prometrium) causes hyperplasia of the endometrium in preparation for implantation of the fertilized ovum; later it helps maintain the pregnancy.

After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn? 1 Protecting the sac with moist sterile gauze 2 Removing buccal mucus and administering oxygen 3 Placing name bracelets on both the mother and infant 4 Transferring the newborn to the neonatal intensive care unit

1 Preventing infection and trauma is the priority; rupture of the sac may lead to meningitis. The Apgar scores are 9 and 10 at 1 and 5 minutes, respectively; oxygen is not needed. Placement of name bracelets on both mother and infant may be done before the infant leaves the birthing room; the priority is care of the infant's sac. The infant's sac must be protected before the infant is transferred to the neonatal intensive care unit.

What should the nurse teach a client about performing breast self-examination? 1 Compress the nipples to check for discharge. 2 Use the right hand to examine the right breast. 3 Press the palm against the breast to compress it to the chest wall. 4 Place a pillow under the shoulder opposite the side being examined

1 Serous or bloody discharge from the nipple is abnormal. The right hand should be used to examine the left breast because this allows the flattened fingers to palpate the entire breast, including the tail (upper outer quadrant toward the axilla) and axillary area. A small pillow or a rolled towel should be placed under the scapula of the side that is being examined. The flat part of the fingers, not the palm or fingertips, should be used for palpation.

A female client asks a nurse about using an intrauterine device (IUD) for contraception. When explaining this method, what common problem should the nurse include in the discussion? 1 The device can be expelled. 2 The uterus may be perforated. 3 Discomfort during intercourse may occur. 4 Vaginal infections are frequent consequences.

1 The IUD may cause irritability of the myometrium, inducing uterine contractions and expulsion of the device; the presence of the IUD thread should be verified after menstruation and before coitus. A perforated uterus is a rare, rather than a common, occurrence. It is not common to have discomfort during coitus (dyspareunia) with an IUD in place; this is one of the warning signs that should be reported. Frequent vaginal infections do not occur with an IUD; if an infection should occur, it usually begins within the first 20 days after insertion.

The nurse is caring for a 1-hour-old newborn. Which assessment characteristics represent a preterm gestational age? 1 Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo: abundant 2 Skin: parchment/wrinkled; breasts: flat areolae, no buds; plantar creases: cover entire sole; lanugo: absent 3 Skin: thin, veins visible; breasts: flat areolae, no buds: plantar creases: covering the entire sole; lanugo: abundant 4 Skin: cracking/few veins; breasts: raised areolae (3- to 4-mm buds), plantar creases: covering the anterior two thirds of the sole; lanugo: thinning

1 The characteristics of preterm, term, and postterm gestational age are based on assessments of physical maturity such as the Ballard or Dubowitz assessment. A preterm infant's skin is translucent, with many visible veins. A term infant has some cracking of the skin and some visible veins, depending on gestational age. Term is any gestation after 38 weeks; veins are less visible at 40 weeks' gestation. The postterm infant typically has dry, leathery, parchmentlike skin with numerous deep wrinkles. The areolae of a preterm infant are flat, without buds, and they become more raised during development, averaging 3 to 4 mm at term and 5 to 10 mm in the postterm infant. The plantar creases develop on the foot during gestation, beginning smooth, then covering two thirds at term, and finally covering the entire sole after term. Lanugo is the fine downy hair that diminishes as the infant develops gestationally.

When the electronic fetal monitor shows contraction occurring every 2 minutes and lasting 95 seconds, the nurse should immediately: 1 Stop the pitocin infusion. 2 Administer oxygen at 8 to 10 L/min. 3 Increase the main line fluid delivery rate to 150 mL/hr. 4 Prepare the client for insertion of an intrauterine pressure catheter

1 The contraction pattern indicates hyperstimulation of the uterus. Stopping the Pitocin infusion permits relaxation of the uterus and perfusion of the placenta. Oxygen cannot reach the placenta until the uterus is relaxed, so administering oxygen will not help. Increasing the rate of delivery of the main line fluid does not affect hyperstimulation of the uterus. Insertion of an intrauterine pressure catheter will only provide measurement of the internal uterine pressure, not affect uterine contractions.

A nurse performs Leopold's maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is: 1 LOA 2 ROA 3 LMP 4 RMP

1 The fetus is in a left occiput anterior (LOA) position because the buttock (firm mass) is in the fundus, the back is on the left, the small parts are on the right, and the head is flexed, indicating an anterior occiput. The right occiput anterior (ROA) position is indicated by the presence of the back on the right side and the cephalic prominence on the left side; the occiput is anterior. The left mentum posterior (LMP) position is marked by cephalic prominence and the back on the same side, indicating an extended head and chin presentation. In the right mentum posterior (LMP) position, the back and cephalic prominence are on the same side (right), indicating an extended head and chin presentation.

A nurse is caring for a pregnant client with type 1 diabetes. This disorder affects her pregnancy by: 1 Increasing the risk of hypertensive states 2 Promoting abnormal placental implantation 3 Causing excessive weight gain because the appetite increases 4 Decreasing the amount of amniotic fluid as the pregnancy progresses

1 The likelihood of gestational hypertension increases fourfold in the client with diabetes mellitus, probably because of a preexisting vascular disorder. Abnormal implantation occurs because of scarring or uterine abnormalities, not because of diabetes. Most pregnant women have an increased appetite; this client's excessive weight gain may be caused by a macrosomic fetus and hydramnios. More than 2000 mL of amniotic fluid (hydramnios, polyhydramnios) is associated with diabetes; its exact cause is unknown. It also occurs with major congenital fetal anomalies, Rh sensitization, and infections (e.g., syphilis, toxoplasmosis, cytomegalovirus, herpes, and rubella).

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next? 1 Placing the newborn under a radiant warmer in the nursery 2 Checking the newborn for a wet diaper and then continue the skin-to-skin contact 3 Leaving the newborn in skin-to-skin contact and rechecking the temperature in 1 hour 4 Double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother's bedside

1 The newborn's temperature should be kept in the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C ). A hypothermic temperature that has not improved in an hour with the use of skin-to-skin contact requires additional measures. The infant should be placed under a radiant warmer for a short time until the temperature returns to the normal range. Continuing skin-to-skin contact would not resolve the problem of hypothermia. Double-wrapping the newborn in warm blankets and leaving the newborn at the bedside would not be an adequate means of resolving the hypothermia.

A newborn is circumcised. What is the most essential nursing assessment during the initial postoperative period? 1 Bleeding 2 Infection 3 Shrill, piercing cry 4 Decreased urine outpu

1 The penis is a vascular area, and the infant must be monitored closely for bleeding. It is too soon to detect signs of infection. Although a circumcised infant may be uncomfortable, he can be medicated for pain; this type of cry may be indicative of central nervous system damage. Decreased urine output is usually not a problem with circumcision.

A preterm infant, born at 30 weeks' gestation, is receiving an intravenous electrolyte solution at a rate of 20 mL/hr by way of an umbilical arterial line. At the hourly intake measurement, the nurse observes that 40 mL has infused in the past hour. What is the nurse's first intervention? 1 Taking the vital signs 2 Comparing the intake with the output 3 Checking the practitioner's prescriptions 4 Slowing the infusion rate to half of the prescribed rat

1 The priority is assessing the infant for circulatory overload; changes in the vital signs may indicate a problem that must be addressed quickly. Comparing the intake and output record wastes valuable time that should be spent assessing the infant's response. Checking the practitioner's prescription wastes valuable time that should be spent assessing the infant's response. After the infant's response is assessed, an adjustment of the IV rate may be prescribed.

During the fourth stage of labor, about 1 hour after giving birth, a client begins to shiver uncontrollably. What should the nurse do? 1 Cover the client with blankets to alleviate this typical postpartum sensation. 2 Check vital signs, because the client may be experiencing hypovolemic shock. 3 Monitor the client's blood pressure, because shivering may cause it to rise. 4 Obtain a prescription for an increase in the rate of the IV fluid infusion to restore the client's fluid reserves.

1 There are several theories about why chilling occurs; one is that it is caused by vasomotor instability resulting from fetus-to-mother transfusion during placental separation; comfort measures such as warm blankets or fluids are indicated. Although the vital signs should be monitored during the fourth stage of labor, they are not being monitored because of the shivering, which is an expected response to the birth. Changes in blood pressure are unexpected. Shivering is not a sign of dehydration.

A 30-year-old gravida 1 para 0 experienced a miscarriage at 10 weeks' gestation. She is Rh negative. In light of this information, the nurse expects: 1 A prescription for one intramuscular microdose (50 mcg) of RhoGAM 2 A prescription for one intramuscular standard dose (300 mcg) of RhoGAM 3 A prescription for one subcutaneous standard dose (300 mcg) of RhoGAM 4 That RhoGAM will not be administered because the pregnancy ended in the first trimester and it is therefore not warranted

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

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? Select all that apply. 1 Cardiac output increases. 2 Blood pressure decreases. 3 The heart is displaced upward. 4 The blood plasma volume peaks. 5 The hematocrit level is lowered.

123 Cardiac output increases during the second trimester because of an increasing plasma volume. The blood pressure decreases because of the enlarged intravascular compartment and hormonal effects on peripheral resistance. As the fetus grows and the enlarging uterus outgrows the pelvic cavity, it displaces the heart upward and to the left. The blood volume starts to increase earlier but does not peak until the third trimester. The reduction in hematocrit occurs in the first trimester; the erythrocyte increase may not be in direct proportion to the blood volume, lowering hematocrit and hemoglobin levels, which remain lower throughout pregnancy.

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? Select all that apply. 1 Cracked and peeling skin 2 Long scalp hair and fingernails 3 Red, puffy appearance of face and neck 4 Vernix caseosa covering the back and buttocks 5 Creases covering the neonate's full soles and palm

125Dry, peeling skin is related to decreased vernix and prolonged immersion in amniotic fluid. Abundant scalp hair and long fingernails are characteristics of postmaturity. These findings are typically noted in a term newborn who is 2 to 3 weeks old. Creases on the entire soles and palms are typical of full-term maturity; preterm newborns have few sole and palm creases. A red, puffy appearance of the face and neck is not a sign of postmaturity; neonates born to diabetic mothers usually have this appearance. Vernix is found on a newborn at about 38 weeks' gestation and disappears after 40 weeks' gestation.

Neonates have difficulty maintaining their body temperature, but their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for a newborn? Select all that apply. 1 Flexed fetal position 2 Hepatic insulin stores 3 Brown fat metabolism 4 Peripheral vasoconstriction 5 Parasympathetic nervous sys

134 Full-term neonates take a flexed fetal position, which conserves heat. Deposition of brown fat begins at 28 weeks' gestation and continues for the rest of the pregnancy; when the newborn's body becomes cool, the sympathetic nervous system stimulates the breakdown of brown fat, which releases heat as a byproduct. Peripheral vasoconstriction helps conserve heat by keeping the central core warm and preventing heat from dissipating. Insulin is not stored in the liver and is not involved with maintenance of neonatal body temperature. The sympathetic, not parasympathetic, nervous system is involved in thermoregulation.

What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? Select all that apply. 1 Pain management with oral analgesics 2 Continuous application of a warm pack 3 Assessment of the site every 15 minutes 4 Gentle cleansing with antibacterial cleanser 5 Application of an ice pack for 20-minute intervals 6 Instructing the client in how to promote normal bowel function

135 Providing pain management will prevent the client's pain from reaching an unmanageable level. Application of ice will decrease pain and edema. Assessment of the site will identify any abnormal changes. Warmth applied to newly traumatized tissue will increase pain and edema. Antibacterial cleanser would be caustic and painful to the laceration. Teaching regarding bowel function would be more appropriately presented after the client has completed the fourth stage and resumed normal intake.

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? Select all that apply. 1 Heparin (Hep-Lock) 2 Clopidogrel (Plavix) 3 Warfarin (Coumadin) 4 Enoxaparin (Lovenox) 5 Acetylsalicylic acid (Acuprin)

14 Heparin (Hep-Lock) may be used during pregnancy because it does not cross the placental barrier and will not cause hemorrhage in the fetus. Enoxaparin (Lovenox) does not cross the placental barrier; its classification for pregnancy is B. Clopidrogrel (Plavix) is a platelet aggregation inhibitor. It is not used for thrombophlebitis; it is used to reduce the risk of brain attack, transient ischemic attack, unstable angina, and myocardial infarction. Warfarin (Coumadin) crosses the placental barrier, causing hemorrhage in the fetus. Acetylsalicylic acid (Acuprin) is a platelet aggregation inhibitor and is not recommended during pregnancy (D category).

The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter? 1 "I'm not exactly sure how an epidural works." 2 "I understand that the epidural might or might not take my pain away." 3 "I signed the consent form for an epidural at my last clinic appointment." 4 "I'm aware that the epidural could cause my contractions to slow down."

1A description of the various anesthetic techniques and what they entail is essential to informed consent, even if the woman received information about analgesia and anesthesia earlier in her pregnancy. Nurses play a part in the informed consent by clarifying and describing procedures or by acting as the woman's advocate and asking the primary health care provider for further explanation. There are three essential components of an informed consent. First, the procedure and its advantages and disadvantages must be thoroughly explained. Second, the woman must agree with the plan of labor pain care as explained to her. Third, her consent must be given freely without coercion or manipulation from her health care provider.

During a newborn assessment a nurse identifies the absence of the red reflex in the eyes. The nurse should: 1 Notify the primary health care provider. 2 Rinse the eyes with sterile saline. 3 Expect edema to subside within a few days. 4 Conclude that this is a result of the prescribed eye prophylaxi

1An absence of the red reflex may be indicative of congenital cataracts. The red reflex is elicited by shining the light of an ophthalmoscope into the newborn's eyes, which should produce a reddish circle. Rinsing the eyes will not affect the red reflex. The red reflex or its absence is not related to edema, which may occur after eye prophylaxis, or to eye prophylaxis itself.

n adolescent gives birth to an infant with a severe cleft palate who is immediately placed on the radiant warmer. After ensuring that there is an adequate airway, the nurse gives the newborn to the mother. Which response to the infant would the nurse anticipate? 1 "Oh no! This is the wrong baby!" 2 "I'm so sad. Do you think I'm being punished?" 3 "My parents will be so upset. What could have happened?" 4 "I shouldn't have had this baby! Now my boyfriend won't marry me

1Denial or disbelief and shock are considered initial grieving responses. There is a feeling of guilt and inadequacy when an infant is born with a defect. It is unusual for a client to initially verbalize feelings of punishment or guilt so directly. A sense of shame and guilt is voiced later, after denial, disbelief, and shock have occurred. It is unusual for a client to use rationalization and voice it so obviously.

A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process? 1 Auscultating the fetal heart 2 Obtaining an obstetric history 3 Determining when the last meal was eaten 4 Ascertaining whether the membranes have ruptured

1Determining fetal well-being takes priority over all other measures. If the fetal heart rate is absent or persistently decelerating, immediate intervention is required. Although obtaining an obstetric history, determining when the client had her last meal, and ascertaining whether the membranes have ruptured are all important, the determination of fetal well-being takes priority.

During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction? 1 Turning the client on her side 2 Notifying the health care provider 3 Checking the vaginal area for bleeding 4 Checking the fetal heart rate every 3 minutes

1Maternal hypotension is a common complication of epidural anesthesia during labor, and nausea is one of the first clues that it has occurred. Turning the client on her side will keep the uterus from putting pressure on the inferior vena cava, which causes a decrease in blood flow. If signs and symptoms do not abate after the client is turned on her side, the health care provider should be notified. Checking the vaginal area for bleeding is not an assessment specific to epidural anesthesia; it is part of the general nursing care during labor. Fetal heart rate monitoring is a continuous process, and the rate should be recorded every 15 minutes; if this monitoring is not being performed, the rate should be checked and recorded every 15 minutes.

When entering the room of a client in active labor to answer the call light, the nurse sees that she ashen gray, dyspneic, and clutching her chest. What should the nurse do after pressing the emergency light in the client's room? 1 Administer oxygen by facemask. 2 Check for rupture of the membranes. 3 Begin cardiopulmonary resuscitation. 4 Increase the rate of intravenous fluids

1The client is exhibiting signs and symptoms of an amniotic fluid embolism; increasing oxygen intake is essential. The client is experiencing an emergency situation; checking for rupture of membranes is irrelevant at this time. The client is breathing and conscious; CPR is not indicated, but it may become necessary if her condition worsens. It is not necessary to increase the IV fluid rate, although the current rate should be maintained.

What instruction is important for the nurse to include when teaching a client about a contraction stress test (CST)? 1 Empty the bladder before the test. 2 Eat nothing for 6 hours after the test. 3 Take the prescribed alprazolam (Xanax) before the test. 4 Be prepared to remain in the hospital for 12 hours after the tes

1The contraction stress test (CST) will take 1 to 2 hours, during which time the client is confined to bed. Movement on and off a bedpan should be avoided. There are no food restrictions before or after this test. Alprazolam (Xanax) may interfere with results of the CST because it will sedate the fetus; if the test is explained adequately, an anxiolytic is not needed. The client may go home 1 hour after the test is completed.

xamination of a client in active labor reveals fetal heart sounds in the right lower quadrant. The head is in the anterior position, is well flexed, and is at the level of the ischial spines. What fetal position should the nurse document? 1 ROA, 0 station 2 LOP, −2 station 3 ROP, −3 station 4 LOA, +1 station

1The fetal heart is in the right quadrant; therefore the fetus's head and back are on the right side. The head is engaged and is at 0 station. In left occiput posterior (LOP) position, −2 station, the fetal heart should be heard on the left side; at station −2 the head is mobile. The information states that the head is anterior and flexed; at −3 station the head is mobile. In left occiput anterior (LOA) position, +1 station the fetal heart should be heard on the left side; at +1 station the head is engaged below the ischial spines.

A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How can the nurse evaluate whether the client's bladder is distended? 1 By catheterizing the client for residual urine 2 By palpating the client's suprapubic area gently 3 By asking the client whether she still feels the urge to urinate 4 By determining whether the client is experiencing suprapubic pain

2

What is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)? 1 Avoid handling the infant to conserve energy. 2 Position the infant to promote respiratory efforts. 3 Assess the infant for congenital birth defects to enable early treatment. 4 Set the incubator thermostat 10° F below body temperature to prevent shivering

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While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection because: 1 Wharton jelly is no longer present. 2 It contains exposed tissue and blood. 3 It is touched by diapers, blankets, and clothing. 4 Newborns do not have immunity to cord infectio

2

Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. Bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor.

2 Anesthesia blocks the sensory pathways; therefore the mother does not sense bladder distention and may be unable to void. Hypotension, not hypertension, is a side effect of epidural anesthesia. An epidural anesthetic does not influence body temperature. A decreased level of consciousness occurs with general anesthesia, not epidural anesthesia; general anesthesia is used when there is an emergency.

Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration. 1 Elevating the legs 2 Repositioning the client from side to side 3 Increasing the rate of intravenous infusion 4 Administering oxygen by way of facemask

2 A deceleration with a rapid descent and ascent to and from the lowest point of the deceleration is a variable deceleration caused by cord compression. Changing the client's position from side to side promotes release of the compression. Oxygen given while the cord remains compressed will not provide fetal oxygenation. Increasing the rate of intravenous fluid administration and elevating the legs are interventions for placental perfusion problems and do not affect cord compression.

After a client has been in labor for 6 hours at home, she is admitted to the birthing room. The client is dilated 5 cm and at −1 station. In the next hour her contractions gradually become irregular and are more uncomfortable. Which possibility should the nurse consider first? 1 The client is in false labor. 2 The client has a full bladder. 3 There is uterine dysfunction. 4 There is a breech presentation

2 A full bladder can impede the forces of labor, and so it must be emptied before any other assessment can be made accurately. The client's cervix is dilating, and therefore she is in true, not false, labor. Before the possibility of uterine dysfunction is considered, the client's bladder should be emptied to relieve the pressure of the bladder on the uterus; the client should then be observed to determine whether regular contractions have resumed. The existence of a breech presentation should have been established during the admission examination.

The nurse is caring for a group of postpartum clients. Which one should the nurse monitor most closely? 1 A primipara who had an 8-lb newborn 2 A grand multipara who just had her sixth child 3 A primipara who received 50 mcg of IV fentanyl during her labor 4 A multipara whose placenta was expelled 15 minutes after the birth

2 A grand multipara is a woman who has had at least 6 births. Multiparity contributes to an increased incidence of uterine atony because the uterine muscle may not contract effectively, leading to postpartum hemorrhage. A primipara should maintain a well-contracted uterus because with only one pregnancy the uterus usually maintains its tone. Fifty micrograms of fentanyl is not considered excessive for a primipara and will not contribute to uterine atony. A multipara is a woman who has given birth to at least two children. The birth of the placenta 15 minutes after birth of the neonate is expected and does not affect uterine tone.

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb at birth. Which finding should be reported immediately to the health care provider? 1 Hemoglobin of 16.2 g/dL 2 Weight of 6 lb 4 oz 3 Total serum bilirubin of 10 mg/dL 4 Three wet diapers over the last 12 hours

2 A loss of 12 oz since birth, or more than 10%, is higher than the acceptable figure of 5% to 6%. Hemoglobin of 16.2 g/dL, total serum bilirubin of 10 mg/dL, and three wet diapers over the last 12 hours are all normal and expected findings.

A client who had tocolytic therapy for preterm labor is being discharged. What instructions should the nurse include in the teaching plan? 1 Restrict fluid intake. 2 Limit daily activities. 3 Monitor urine for protein. 4 Avoid deep-breathing exercises

2 Although it has not been proved that bedrest limits preterm labor, it is often recommended; activities are restricted to bathroom privileges and movement to a daytime resting area. Fluid intake should not be restricted; hydration should be maintained. Monitoring of the urinary protein level is included in the care of a client with preeclampsia, not preterm labor. Deep-breathing exercises do not influence preterm labor.

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder? 1 Maintaining sterility of the exposed bladder 2 Measuring output from the exposed bladder 3 Protecting the skin surrounding the exposed bladder 4 Applying a pressure dressing to the exposed bladder

3 Constant drainage of urine on the skin promotes excoriation and infection, so the skin must be protected. Sterility is impossible to maintain because of the leakage of urine. Output will be difficult to measure because of the constant leakage of urine. A pressure dressing is contraindicated because it will traumatize the exposed bladder.

For what finding should a nurse assess the newborn of a mother who is known to abuse opioids? 1 Dehydration 2 Hyperactivity 3 Hypotonicity of muscles 4 Prolonged periods of sleep

2 As the opioid is cleared from the newborn's body, signs of withdrawal become evident. Tremors, irritability, difficulty sleeping, twitching, and convulsions result. Dehydration is a result of inadequate feeding; it is not a direct result of opioid withdrawal. Muscle hypertonicity, not hypotonicity, occurs with opioid exposure. Opioid withdrawal results in signs of excessive stimulation.

A newborn was delivered 25 minutes earlier. Once identification bands have been applied and vital signs have been taken, what interventions does the nurse need to complete? Place these actions in the order of their priority. 1. Performing a head-to-toe physical examination 2. Assisting the new mother with breastfeeding 3. Taking and recording weight and height 4. Placing the infant under a warmer and attaching a sensor probe 5. Giving erythromycin eye ointment and a vitamin K shot

2 Assisting the mother with breastfeeding is the priority at this time. Just after birth, the newborn is awake and alert, an ideal time for bonding and attempting breastfeeding. If breastfeeding is not the feeding choice, the newborn should be placed, skin to skin, on the mother. Bonding soon after birth by touching and caressing the newborn is important. Breastfeeding and the bonding process are most important at this time, not separation. Performing a head-to-toe physical examination is not the priority; this may be done later. Measuring and documenting infant weight and height can also be done later. The newborn will be warm in the mother's arms.

A nurse is obtaining the health history from a client with a diagnosis of ruptured tubal pregnancy. At what point in the pregnancy does the nurse expect the client to state that the low abdominal pain and vaginal bleeding started? 1 At the end of the first trimester 2 Around the sixth week of pregnancy 3 Midway through the second trimester 4 When the first menstrual period was missed

2 At the sixth week of pregnancy the products of conception have become too large for the tube to accommodate them, and rupture occurs. Tubal pregnancies cannot advance to the end of the first trimester or into the second because of the tube's inability to expand to accommodate a pregnancy of this size. The embryo is recognizable when the first menstrual period is missed (about 2 weeks after fertilization), but it is too small at this point to cause the tube to rupture.

A client with a high-risk pregnancy is to undergo a contraction stress test (CST). Which factor would compel the nurse to question the order? 1 Blurred vision 2 Vaginal bleeding 3 Sickle cell disease 4 Increasing hypertension

2 Bleeding may indicate placenta previa or abruptio placentae, which will be aggravated by contractions from the use of oxytocin. Although blurred vision may indicate preeclampsia, a CST is not contraindicated. Fetal tolerance of the stress of contractions should be assessed. Although sickling or arteriolar spasms could diminish oxygen perfusion to the placenta and compromise the fetus during labor, a CST is not contraindicated.

Which finding indicates the development of a complication resulting from the presence of bilateral cephalhematomas? 1 Urine output 2 Skin color 3 Glucose level 4 Rooting/sucking reflex

2 Cephalhematomas are gradually absorbed. As the hematoma resolves, hemolysis of red blood cells occurs, and jaundice may result. Glucose level, urine output, and the rooting/sucking reflex are not affected by a cephalhematoma.

A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect? 1 HIV infection 2 Chlamydia trachomatis infection 3 Retinopathy of prematurity (retrolental fibroplasia) 4 A reaction to the ophthalmic antibiotic instilled after birth

2 Chlamydia trachomatis infection occurs 3 to 4 days after birth; if it is not treated prophylactically with an antibiotic at birth or within 3 days, chronic follicular conjunctivitis with conjunctival scarring will occur. HIV infection in the newborn does not manifest with conjunctivitis. The high oxygen concentrations given to severely compromised preterm infants cause vasoconstriction of retinal capillaries, which can lead to blindness; there are no data to indicate that this infant was preterm, severely compromised, or received oxygen. A chemical conjunctivitis occurs within the first 48 hours and is not purulent.

The nurse is helping a mother breastfeed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast? 1 The tongue is securely on top of the nipple. 2 The mouth covers most of the areolar surface. 3 Loud sucking sounds are heard during the 15 minutes spent at each breast. 4 Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep.

2 Effective attachment involves covering most of the areolar surface of the breast with the newborn's mouth; effective attachment helps compress the milk glands. The nipple must be on top of the newborn's tongue. Loud sucking sounds indicate inadequate attachment. The newborn should suckle for a longer period; the newborn may be sucking only on the nipple.

Why should a nurse withhold food and oral fluids as a laboring client approaches the second stage of labor? 1 The mechanical and chemical digestive processes require energy that is needed for labor. 2 Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia. 3 The gastric phase of digestion stimulates the release of hydrochloric acid and may cause dyspepsia. 4 Food and fluid will further aggravate gastric peristalsis, which is already increased because of the stress of labor.

2 Gastric peristalsis often ceases during periods of stress. Abdominal contractions put pressure on the stomach and can cause nausea and vomiting, increasing the risk for aspiration. Although it is true that the increased acid secretion during the gastric phase may cause dyspepsia, it is not the reason for withholding food and oral fluids during labor; the primary reason for withholding it is the prevention of aspiration. Gastric peristalsis is decreased, not increased, during the stress of labor and birth.

A client starting her second trimester asks a nurse in the prenatal clinic whether she can safely take an over-the-counter (OTC) medicine now that she is past the first 3 months of pregnancy. The nurse explains why she should consult with her health care provider before taking any oral medications. What physiologic alteration associated with pregnancy may change the client's response to medication? 1 Decreased glomerular filtration rate 2 Longer gastrointestinal emptying time 3 Increased secretion of hydrochloric acid 4 Development of fetal-placental circulation

2 Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and the intestines laterally and posteriorly; absorption of some drugs, vitamins, and minerals may be increased because of their slow passage through the gastrointestinal tract. The glomerular filtration rate increases during pregnancy. The amount of gastric secretion is somewhat lower in the first and second trimesters; it increases in the third trimester. The development of fetal-placental circulation is unrelated to the absorption of drugs.

Why does a nurse encourage continued health care supervision for a pregnant woman with pyelonephritis? 1 Preeclampsia frequently occurs after pyelonephritis. 2 Antibiotic therapy should be administered until the urine is sterile. 3 Pelvic inflammatory disease may occur with untreated pyelonephritis. 4 Nutritional needs change to accommodate the prescribed low-protein diet

2 Health care supervision requires treatment with an appropriate antibiotic until two cultures of urine are negative; recurring pyelonephritis often leads to preterm birth. Preeclampsia is not preceded by specific infections. Pelvic inflammatory disease is associated with infections of the genital, not the urinary, tract. A low-protein diet inhibits fetal development and is contraindicated during pregnancy.

A neonate born at 39 weeks' gestation is small for gestational age. What commonly occurring problem should the nurse anticipate when planning care for this infant? 1 Anemia 2 Hypoglycemia 3 Protein deficiency 4 Calcium deficienc

2 Hypoglycemia is common in newborns who are small for gestational age because of malnutrition in utero; the nurse can detect this with a blood glucose test and notify the primary health care provider. Polycythemia, not anemia, is more likely to occur. Although a protein deficiency may occur, it is not life threatening at this time. Although hypocalcemia may occur, it is not as common as hypoglycemia.

The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with: 1 Fetal lie 2 Fetal movement 3 Maternal blood pressure 4 Maternal uterine contractions

2 In a healthy well-oxygenated fetus the heart rate increases with fetal movement; there should be an acceleration of 15 beats with fetal movement. Fetal lie is not a part of the evaluation of the fetus in the nonstress test. Maternal blood pressure is not a part of the evaluation of the fetus in the nonstress test. Maternal uterine contractions are used in the contraction stress test.

A client having her labor induced with oxytocin has internal fetal monitoring in place. Her contractions are occurring every 2 minutes, are lasting 70 seconds, and are reaching 65 mm Hg on an intrauterine pressure catheter. The baseline fetal heart rate is 130 to 140 beats/min with variability of about 15 beats/min. The nurse notices that with the last two contractions the fetal heart rate began to drop during the peak of the contraction to 110 beats/min, where it remained for about 40 seconds before returning to baseline. What type of pattern is this? 1 Bradycardia 2 Late decelerations 3 Early decelerations 4 Variable decelerations

2 Late decelerations begin during the peak of a contraction and continue after the contraction has ended. Bradycardia is a fetal heart rate slower than 110 beats/min for 10 minutes. Early decelerations mirror the contraction, beginning at the start of the contraction and ending when the contraction is over. Variable decelerations fall and rise abruptly and do not have the uniform appearance noted with early and late decelerations.

As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. What does the nurse conclude about this occurrence? 1 It is the precursor of newborn diarrhea. 2 It is a common finding in 2-day-old neonate. 3 It is a pathological condition of the digestive system. 4 It reflects immaturity of the autonomic nervous system

2 Meconium is passed usually during the first several days of life, and it has no relationship to the pathological condition of diarrhea. Passage of meconium is desirable in the newborn because it indicates patency of the colon and a perforate anus. Although the newborn's autonomic nervous system is not fully developed at birth, gastrointestinal function is adequate to meet digestive, absorption, metabolic, and elimination needs.

A new mother asks the nurse whether she may wash her baby in a tub after they go home. What is the nurse's best response?" 1 "Yes, as long as you don't leave the baby unattended." 2 "Babies can be bathed in a tub after the cord has fallen off." 3 "Yes, but warm the water first to keep from chilling the baby." 4 "Babies shouldn't be bathed in a tub until they can sit alone."

2 Only after the cord has fallen off should an infant be tub bathed; tub bathing before then increases the risk of infection by way of the moist umbilical stub. Although infants should be attended at all times during a bath, immersion in water at this age is inappropriate. Although the prevention of chilling is important, immersion in water at this time is inappropriate. It is not necessary to wait to tub bathe an infant until the infant is able to sit alone.

The nurse is admitting a client to the unit after fetal death was confirmed by ultrasound. While initiating intravenous therapy the nurse notes blood continually oozing from the puncture site. What is the nurse's next action? 1 Restarting the line distal to the initial site 2 Informing the health care provider of this finding 3 Starting the ordered infusion of oxytocin (Pitocin) 4 Placing an oxygen mask on the client and setting the flow rate at 8 L/min

2 Oozing from a venipuncture site is a sign that disseminated intravascular coagulopathy (DIC) is developing. This pathologic form of clotting causes widespread bleeding and clotting. It is never a primary diagnosis; it always results from some problem that has triggered the clotting cascade. The health care provider must be informed because this diagnosis may change the client's plan of care. There is no information indicating the need for a different IV site. Also, subsequent venipunctures must be proximal and not distal to previous sites. Delivery will likely be managed initially with Pitocin; however, this is not the first action to be taken in regard to an oozing IV site. Generally oxygen is started for signs of hypoxia, fetal or maternal; because there is no fetal indication for oxygen and no information in the stem indicating maternal hypoxia, application of oxygen is not the next intervention.

A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated. The nurse explains to the parents that this is done to prevent: 1 Failure to thrive 2 Cognitive impairment 3 Growth restriction 4 Specific food allergies

2 Screening for PKU facilitates early diagnosis and treatment, which can prevent mental retardation. Although children with untreated PKU do have problems with physical growth and may exhibit failure to thrive, the major purpose of the test is to prevent the development of cognitive impairment. Telling the parent that this test is performed to prevent specific food allergies is not accurate because this is not a test for food allergies; it tests for an inborn error of metabolism, PKU.

couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse? 1 "I'll get your grandchild. You must be very excited." 2 "Please go on to see your daughter. I'll bring the baby to her room." 3 "Show me your identification. I need to see it before I can give you the baby." 4 "Only the mother can ask for the baby. Have her call us to bring the baby to her."

2 Telling the couple that the baby will be brought to the client's room maintains the nurse's legal responsibility of providing for the infant's safety while still promoting a positive interaction with the client's family. Giving the infant to another person without the mother's knowledge or consent is illegal. Legally the nurse may not give the infant to the grandparents. Although insisting that only the mother can ask for the infant may follow legal policy, it is an abrupt nontherapeutic response to the grandparents.

A client is admitted in active labor. The nurse, performing Leopold maneuvers, determines that the fetus is in the left occiput anterior (LOA) position. Where should the nurse place the transducer of the electronic fetal monitor? 1 Right lower midline 2 Left lower quadrant 3 Left upper quadrant 4 Right upper quadrant

2 The LOA position indicates that the fetus is on the left side of the mother and in a head presentation with the occiput anterior; therefore fetal heart sounds are best found in the left lower quadrant of the woman's abdomen. If the fetal heartbeat is found toward the right lower midline of the mother's abdomen, the fetus is probably in a shoulder presentation, in the right scapular anterior position. If the fetal heartbeat is found in the left upper quadrant of the mother's abdomen, the fetus is in the breech presentation on the left side of the mother (left sacrum anterior). If the fetal heartbeat is found in the right upper quadrant of the mother's abdomen, the fetus is in the breech presentation on the right side of the mother (right sacrum anterior).

While changing a newborn girl's diaper a nurse observes a brick-red stain on the diaper. How does the nurse interpret this clinical finding? 1 A sign of low iron excretion 2 An uncommon benign occurrence 3 An expected occurrence in female newborns 4 The result of a medication administered during labor

2 The brick-red color is caused by albumin and urates that are in the urine, which are found in the first week of life. Iron is eliminated by way of the gastrointestinal tract. The finding is unrelated to the sex of the infant; it is not hormonally based. No medication administered during labor will cause this discoloration.

A nurse is caring for a primigravida during labor. What does the nurse note that indicates that birth is about to take place? 1 Bloody discharge from the vagina is increasing. 2 The perineum has begun to bulge with each contraction. 3 The client becomes irritable and stops following instructions. 4 Contractions occur more frequently, are stronger, and last longer.

2 The bulging perineum indicates that the fetal head is on the pelvic floor and birth is imminent. Contractions occurring more frequently that are stronger and last longer are part of the progress of labor, not a sign that birth is imminent. An increase in bloody show and an increasingly irritable client are seen during the transition phase or at the beginning of the second stage.

A client with a history of phenylketonuria (PKU) who was maintained on a low-phenylalanine diet until 9 years of age is pregnant. What is most important for the nurse to discuss with this client? 1 The infant may be developmentally disabled because of her history of PKU. 2 Reinstitution of the low-phenylalanine diet will protect her baby from the disorder. 3 The fetus is not at risk prenatally but will require immediate care at birth to prevent PKU. 4 The client should avoid phenylalanine even when she is not pregnant so her body is able to support a pregnancy.

2 The fetus is at risk from a buildup of metabolites in the PKU-affected mother if the prescribed diet is not followed. The infant will not be affected if a low-phenylalanine diet is maintained by the mother during pregnancy; also, the infant may inherit PKU by way of an autosomal recessive gene. The client should restart a phenylalanine-restricted diet when planning to become pregnant and continue it throughout pregnancy.

Identify the position of the fetus whose buttocks are in the fundus, whose fetal back is on the maternal right side between the midline, and lateral surface of the abdomen, and whose attitude is general flexion. 1 RSA 2 ROA 3 RMA 4 LOA

2 The fetus is in the ROA (right occiput anterior) position: occiput facing the front on the right side of the mother). It is a vertex delivery. In the RSA (right sacrum anterior) position the buttocks point anteriorly on the mother's right side. RMA (right mentoanterior) is a brow presentation. In LOA (left occiput anterior), another vertex position, the fetus's back is on the mother's left side.

A client with a history of a congenital heart defect is admitted to the birthing unit in early labor. What position does the nurse encourage the client to assume? 1 Supine 2 Semi-Fowler 3 Trendelenburg 4 Left lateral recumben

2 The head of the bed should be elevated 45 degrees; this permits maximal chest expansion for ventilation. The laboring woman should not assume the supine position, because this would increase the risk of hypotension as a result of decreased venous return. The Trendelenburg position interferes with optimal cardiac function during labor and is contraindicated.

After a deep vein thrombosis developed in a postpartum client, an IV infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do? 1 Increase the intravenous rate of heparin. 2 Interrupt the infusion and notify the practitioner of the aPTT result. 3 Document the result on the medical record and recheck the aPTT in 4 hours. 4 Call the practitioner to obtain a prescription for a low-molecular-weight heparin.

2 The heparin should be withheld, because 98 seconds is almost three times the normal time it takes a fibrin clot to form (25 to 36 seconds) and prolonged bleeding may result; the therapeutic range for heparin is one-and-a-half to two times the normal range. The primary health care provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe opeion. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.

A nurse determines that the fetus of a client in labor is in the left sacrum anterior position. Where should the nurse place the fetal heart transducer on the client's abdomen? 1 Left lower quadrant 2 Left upper quadrant 3 Right upper quadrant 4 Midline lower quadrant

2 The left sacrum anterior position indicates that the fetus is in a breech presentation and the head is in the fundus; fetal heart sounds are best heard in the left upper quadrant. Fetal heart sounds will be in the left lower quadrant if the fetus is in the left occiput anterior position. Fetal heart sounds will be in the right upper quadrant if the fetus is in the right sacrum anterior position. The fetal heart sounds will not be heard in the midline part of a lower quadrant in a single-fetus pregnancy.

During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat? 1 Liver and raisins 2 Cheese and broccoli 3 Eggs and lean meats 4 Whole-wheat breads and cereals

2 The leg cramps may be related to low calcium intake; cheese and broccoli each have a high calcium content. Although liver and raisins, eggs and lean meats, and whole-wheat breads and cereals are recommended as part of a high-quality nutritional intake, they are inadequate sources of calcium.

Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy? 1 Covering the trunk to prevent hypothermia 2 Using shields on the eyes to protect them from the light 3 Massaging vitamin E oil into the skin to minimize drying 4 Turning after each feeding to reduce exposure of each surface area

2 The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed.

What should the nurse do when an apnea monitor sounds an alarm 10 seconds after cessation of respirations? 1 Assess for changes in skin color. 2 Use tactile stimuli on the chest or extremities. 3 Check the monitor for signs of a malfunction. 4 Resuscitate with a facemask and an Ambu bag

2 The nurse applies tactile stimulation after confirming that respirations are absent; this action may be sufficient to reestablish respirations in the high-risk neonate with frequent episodes of apnea. Assessment will not interrupt the period of apnea; respirations must be reestablished immediately. The monitor should be assessed for proper function before use. Resuscitation with a bag-valve mask is too invasive and aggressive for an initial intervention; gentle stimulation should be attempted first.

To determine the presence of respiratory alkalosis in the laboring client, the nurse should assess her for: 1 A change in the respiratory rate 2 A tingling sensation in the hands 3 Periodic changes in the fetal heart rate 4 A pulse oximetry reading of less than 98%

2 The presence of a tingling sensation in the hands indicates respiratory alkalosis due to a decrease in carbon dioxide. A change in respiratory rate is incorrect because although such a change may contribute to respiratory alkalosis, it is not evidence of an increase in pH. A pulse oximetry reading of 98% is incorrect because it is not an abnormal finding. In the presence of maternal respiratory alkalosis, chemical changes in maternal erythrocytes facilitates oxygen release to the fetus, which maintains a normal fetal heart rate.

A nurse in the prenatal clinic is caring for a pregnant client with well-controlled type 1 diabetes. What does the nurse anticipate for this client? 1 Cesarean birth 2 Intensive prenatal care 3 High perinatal mortality 4 Decreased insulin requirements

2 There is a constant need for evaluation of diabetic status, fetal maturity, and placental function; if the pregnancy is well managed, the outcome should be the same as for a healthy pregnancy. A client with well-controlled diabetes should be able to have a vaginal birth. If the diabetes is well controlled, the risk of perinatal mortality is the same as in the rest of the pregnant population. Insulin requirements vary and usually are increased during the second and third trimesters of pregnancy.

What is the most appropriate time for the nurse to administer an intravenous opioid analgesic to a client in active labor? 1 Between contractions 2 When a contraction starts 3 At the peak of a contraction 4 Just before the end of a contraction

2 When an analgesic is administered at the beginning of a contraction, uterine muscle tension increases resistance to the absorption of the medication, thereby slowing its passage through the placenta to the fetus. Between contractions is when the uterine muscle is at its most relaxed, and giving the analgesic at this time thereby increases the rate of the opioid's passage through the placenta to the fetus. Although giving the analgesic at the peak of a contraction will decrease the rate of the opioid's passage through the placenta, it is not the time of maximum resistance. There will be minimum resistance to the opioid's passage through the placenta just before the end of a contraction.

A nurse teaches the mother of a newborn with phenylketonuria (PKU) why it is important to restrict the amount of phenylalanine in her infant's formula. Because all proteins contain this essential amino acid, the nurse suggests appropriate formulas. Which formulas are safe for this infant? Select all that apply. 1 Isomil 2 Phenex 3 Enfamil 4 Prosobee 5 Lofenalac

25 Phenex is a milk substitute that contains casein hydrolysate, which provides 0.4% phenylalanine. The infant's blood level of phenylalanine must be kept below 8 mg/dL to prevent protein catabolism; however, the blood level must remain above 2 mg/dL to promote growth and development. Lofenalac is a milk substitute that contains only 0.4% phenylalanine; it is a safe milk substitute for an infant with PKU. Isomil, Enfamil, and Prosobee all contain more than the recommended amount of protein.

A client is transferred to postpartum care 1 hour after a spontaneous vaginal delivery because the bed is needed for another laboring client. On assessment the nurse finds the fundus at U-1 and firm and the pad saturated with blood. The pad is changed and reassessed 15 minutes later, and again found saturated with blood. The fundus remains at U-1, midline and firm. Place the interventions in order of priority. 1. Taking vital signs 2. Assessing the episiotomy 3. Calling the health care provider 4. Weighing pads to measure blood loss 5. Assessing the client for a vaginal laceration

25413 Gather assessment data before calling the health care provider by checking the episiotomy for bleeding, assessing the client for a hematoma, weighing pads as soon as postpartum hemorrhage is suspected to provide a more accurate amount of blood loss (1 g of pad weight = 1 mL of blood), and taking vital signs. The health care provider should see the client to determine whether she has sustained a laceration(s), or if placental fragments or other problems are present. Because the fundus is firm at U-1 and midline, uterine atony would not be suspected.

A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? Select all that apply. 1 The infant cries without noise. 2 Aspiration produces a small quantity of light-yellow or light-green liquid. 3 The tube is inserted to a depth from the ear to the tip of the nose to the sternum. 4 A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. 5 Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic.

25\ Aspirated fluid that is either light green or yellow indicates gastric contents. The Nitrazine strip test provides reliable proof that the tube is in the stomach. The tube is in the trachea, not the esophagus; when a tube crosses through the larynx, the infant is unable to vocalize. Although this is the correct measurement of the length of tube to be inserted, it is not a guarantee that the tube is in the stomach. The "whoosh test" is no longer used to verify placement of the tube because evidence has shown that it is not reliable.

Five minutes after a birth the nurse-midwife determines that the client's placenta is separating. What indicates that this is occurring? 1 Uterine fundus relaxes 2 Umbilical cord lengthens 3 Abdominal pain becomes severe 4 Vaginal seepage of blood is continuou

2As the placenta separates and descends down the uterus, the cord descends down the vaginal canal and therefore appears to lengthen. The fundus contracts and becomes rounded and firmer. The client may feel a contraction, but it is not as uncomfortable as the painful contractions at the end of the first stage of labor. Continual seepage occurs in the presence of hemorrhage; a sudden large gush of blood heralds placental separation.

What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include? 1 Examining for a cleft palate 2 Testing for congenital syphilis 3 Assessing the infant for muscle hypotonicity 4 Inspecting the soles for maculopapular lesion

2Because physical signs of congenital syphilis are difficult to detect at birth, the infant should be screened immediately to determine whether treatment is necessary. Cleft palate is a congenital defect that occurs in the first trimester; Treponema pallidum does not affect a fetus before the 16th week of gestation. Muscle hypotonicity is found in children with Down syndrome, not those with congenital syphilis. Maculopapular lesions of the soles do not manifest in the infant with congenital syphilis until about 3 months of age.

hat does a nurse anticipate will be provided for the newborn of a mother with a long history of diabetes? 1 Fast-acting insulin 2 Special high-risk care 3 Routine newborn care 4 Limited glucose intak

2The infant of a diabetic mother is a newborn at risk because of the interaction between the maternal disease and the developing fetus. The newborn of a mother with type 1 diabetes generally is hypoglycemic because of oversecretion of insulin by the newborn's hypertrophied pancreas. The newborn of a mother with type 1 diabetes is at high risk and requires intensive care. The newborn of a mother with type 1 diabetes is prone to hypoglycemia and will probably need increased glucose.

A nurse is assessing a primigravida who was admitted in early labor after her membranes ruptured. She is at 41 weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor? 1 Encourage her to watch television. 2 Take a walk around the unit with her. 3 Ask her to maintain a left-lateral position.

2Walking may increase the frequency and intensity of the contractions. Although watching TV may be a relaxing activity, it will not help stimulate labor. At this time there is no indication that the client should assume the left-lateral position. During early labor, slow chest or abdominal breathing helps the client relax; the patterned, paced breathing technique is more appropriate for the transition phase of labor.

On a 6-week postpartum visit a new mother tells a nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach her that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for: 1 Fat and calcium 2 Vitamin C and iron 3 Thiamine and sodium 4 Protein and carbohydrates

2Whole milk does not meet the infant's need for vitamin C and iron. It contains adequate fats, but the calcium content is 3½ times that of human milk. Whole milk contains adequate thiamine, but the sodium content is 3 times that of human milk. Whole milk contains adequate carbohydrates, but the protein content is 3 times that of human milk.

A nurse is caring for pregnant clients in the high-risk unit. In what disorder is stimulation of labor contraindicated? 1 Diabetes mellitus 2 Mild preeclampsia 3 Total placenta previa 4 Premature rupture of the membranes

3

A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at −2. For what complication should the nurse assess when caring for this client? 1 Vaginal bleeding 2 Urinary tract infection 3 Prolapse of the umbilical cord 4 Meconium in the amniotic fluid

3 A breech presentation results in a larger space between the cervix and the fetal sacrum than does a vertex presentation. When the client is a multipara, the muscle tone of the cervix may be relaxed; therefore the umbilical cord may prolapse and become compressed, leading to fetal hypoxia and potential fetal demise. Unless there are other complications, vaginal bleeding is not expected. A urinary tract infection is not related to a breech presentation. As the fetal sacrum is compressed during labor, meconium may be expelled; this is not a fetal life-threatening concern with a breech presentation.

A new mother is feeding her baby girl, who was born 36 hours ago in a spontaneous vaginal delivery. The nurse notices that the mother is crying and points to the top of her baby's head. She cries, "I don't know what's wrong with my baby! She didn't have this big lump on the right side of her head before now. I haven't dropped her! What happened to her?" What is the best response once the nurse has assessed the infant's head? 1 "Your baby's head is just slightly elongated, and that's nothing to be concerned about." 2 "She'll be examined again by the pediatrician before you leave later today, so there's no need to worry right now." 3 "Your baby may have a condition called cephalhematoma. It's common, but I'll make a note to have the pediatrician assess it." 4 "Your baby may have a condition called caput succedaneum, which is common. I'll make a note to have the pediatrician assess it."

3 A cephalhematoma usually develops on one side of the head over the parietal bones. The swelling is not generally present at birth; instead, it develops over the first 24 to 48 hours of life. Caput succedaneum appears over the vertex of the newborn's head and causes localized edema that varies in size. It is seen shortly after birth and resolves within 12 hours to several days after birth. Telling the mother not to worry dismisses her fears.

A client is being prepared for an emergency cesarean birth because of nonreassuring fetal signs. What is most important for the nurse to determine before surgery? 1 Whether an indwelling catheter has been inserted 2 Whether an intravenous infusion has been started 3 Whether a signed consent is included in the client's record 4 Whether the client's abdomen has been prepared for surgery

3 A cesarean birth is an invasive procedure. It is imperative that a signed consent be obtained before the induction of anesthesia, because the client's judgment may be altered by anesthesia. Inserting an indwelling catheter, starting an intravenous infusion, and preparing the client's abdomen for surgery may all be done later, even after anesthesia has been administered.

A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider about breech presentations when caring for this client? 1 Severe back discomfort will occur. 2 Length of labor usually is shortened. 3 Cesarean birth probably will be necessary. 4 Meconium in the amniotic fluid is a sign of fetal hypoxia

3 A cesarean birth may be performed when the fetus is in the breech presentation because the risk of morbidity and mortality is increased. A vertex presentation in the occiput posterior position usually causes back pain. Labor is usually longer with a fetus in the breech presentation because the buttocks are not as effective as the head as a dilating wedge. Meconium is a common finding in the amniotic fluid of a client whose fetus is in a breech presentation because contractions compress the fetal intestinal tract, causing release of meconium.

A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is in labor. What does the nurse do to verify that the client is in true labor? 1 Times uterine contractions 2 Obtains a specimen for a fern test 3 Interprets findings of the pelvic examination 4 Applies Nitrazine paper to moist vaginal tissue

3 A pelvic examination should reveal cervical dilation and effacement if the client is in true labor. Contractions may be present with false labor; they are called preparatory contractions. Ferning is the characteristic frondlike pattern of crystallization in amniotic fluid when it dries; this test is used to confirm the rupture of membranes. Nitrazine testing is used to differentiate amniotic fluid from urine; the onset of true labor may occur with or without the rupture of membranes.

What is the focus of nursing care for a newborn with respiratory distress syndrome (RDS)? 1 Turning the infant frequently to prevent apnea 2 Tapping the toes to stimulate respirations 3 Keeping warm to maintain body temperature at 98° F (37° C) 4 Maintaining oxygen concentration at 40% to support respiratio

3 A warm environment is most important because if the neonate has to maintain body temperature it will further compromise physical status by increasing metabolic activity and oxygen demand. Frequent turning and stimulation are both is contraindicated because increased activity increases oxygen demands. The oxygen percentage will vary with the neonate's Po2 values; the concentration of oxygen should never be set at a fixed amount.

he nurse, providing discharge instructions to the parents of a male newborn, asks them to repeat the findings that should prompt them to call the health care provider. Which finding indicates a need for further education? 1 Failure to urinate 2 Displacement of the Plastibell 3 A yellowish exudate around the incision 4 Bleeding of more than a few drops after the first diaper change

3 A yellowish exudate forms around the circumcision site during normal healing. Bleeding should be minimal after the procedure and should stop after the first few diaper changes. Signs of complications after circumcision include the continued presence of blood in the diaper after the first few changes, failure of the infant to urinate after 8 hours, and displacement of the Plastibell, which could cause injury and swelling of the glans.

A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing? 1 Placenta previa 2 Precipitous birth 3 Abruptio placentae 4 Breech presentation

3 Abruptio placentae indicates premature placental separation; the classic signs are abdominal rigidity, a tetanic uterus, and dark-red bleeding. Placenta previa occurs with a low-lying placenta and is manifested by painless bright-red bleeding. Information on cervical effacement, dilation, and station is required before the nurse can come to this conclusion. Fetal presentation is not related to the client's signs and symptoms.

Five minutes after being born, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score? 1 3 2 4 3 5 4 6

3 According to the Apgar scoring system, the newborn receives 2 points for heart rate, 0 for color, 1 for respiratory effort, 1 for muscle tone, and 1 for reflex irritability. An Apgar score of 3 is low. Scores of 5 and 6 are higher, but the newborn may still require stimulation and oxygen.

A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time? 1 Bringing the infant as requested before she changes her mind 2 Describing how the infant looks before bringing the infant to her 3 Staying with her after bringing the infant to help her verbalize her feelings 4 Showing the mother pictures of the birth defects, then bringing the infant to her

3 Allowing the client time to talk about her feelings and staying with her when she sees the infant for the first time are measures that will provide support, acceptance, and understanding. Bringing the infant to the mother as requested does not allow the mother adequate time to prepare to see her infant. Anomalies are difficult to describe accurately in words, especially when the mother has not been given time to express her feelings. Showing pictures may not be helpful, and discussion of treatment is premature.

When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding? 1 They are common and will disappear in 2 to 3 days. 2 They are birthmarks that will disappear in 3 to 4 months. 3 Avoid squeezing them and don't try to wash them off. 4 Proper handwashing technique is important because milia are infectious

3 Although milia are common, they do not disappear for several weeks after birth. Milia are not birthmarks; the tiny plugged sebaceous glands are the result of maternal hormonal influence. Attempts to remove milia will irritate the infant's skin, and such attempts are not needed because the milia will disappear during the first month of life. The white material is not purulent and is not infectious.

newborn boy is placed on his mother's abdomen immediately after birth and starts to suck on his fist. His mother asks the nurse, "Why is he doing that?" What is the most appropriate response by the nurse? 1 "He's expressing his insecurity outside the uterus." 2 "He's hungry and needs to nurse as soon as possible." 3 "Sucking prepares him for when he starts to nurse later." 4 "Sucking indicates that he's upset and tired from the birth process

3 An active sucking reflex is a typical response of a healthy full-term newborn, especially after an uneventful birth. Newborns show distress by vigorous crying, not by sucking. A neonate sucks at various times; sucking is a reflex in the newborn and is not the sole indicator of hunger.

A nurse who is assessing a full-term newborn elicits the magnet reflex. How is this reflex elicited? 1 Striking the surface of the newborn's crib suddenly 2 Stroking the outer sole of the newborn's foot from the heel to the little toe 3 Maintaining the supine position and applying pressure to the soles of the newborn's feet 4 Holding the newborn's body upright and allowing the feet to touch the surface of the crib

3 Applying pressure to the sole of the foot produces the magnet reflex, in which the legs extend in response to the pressure on the soles of the feet. Jarring the crib produces a startle response (Moro reflex). Stroking the outer sole of the foot from the heel to the little toe produces the Babinski or plantar reflex; all of the toes hyperextend. Allowing the feet to touch the surface of the crib produces the stepping reflex, in which one foot is placed before the other in a simulated walk, with the weight on the toes.

Which nursing assessment is most important for a large-for-gestational-age (LGA) infant of a diabetic mother (IDM)? 1 Temperature less than 98° F (36.6° C) 2 Heart rate of 110 beats/min 3 Blood glucose level less than 40 mg/dL 4 Increasing bilirubin during the first 24 hours

3 At birth, circulating maternal glucose is removed; however, the IDM still has a high level of insulin, and rebound hypoglycemia may develop. The temperature-regulating ability of an IDM is similar to that of a healthy neonate, unless the IDM is preterm. A heart rate of 110 beats/min is within the expected range for a newborn. Pathologic jaundice is associated with hemolytic diseases such as Rh and ABO incompatibilities and sepsis, not maternal diabetes.

A client is admitted to the birthing room in active labor. She is gravida IV, para III. When she is at 8 cm of dilation, her membranes rupture spontaneously. What should the nurse do after assessing fetal well-being? 1 Notify the practitioner. 2 Document the occurrence. 3 Perform a vaginal exam. 4 Change the client's underpad.

3 Because the client is a multigravida, the fetal head may not have engaged in the pelvis, so the umbilical cord may prolapse and become compressed as the fetal head descends; immediate intervention is required if the cord has prolapsed. More data are needed before the practitioner is notified. After it is determined that the umbilical cord has not prolapsed and the fetus's heart rate is within expected limits, documentation may be performed. After it is determined that the umbilical cord has not prolapsed, the client's bedding may be changed.

A woman in labor arrives at the birthing unit. She tells the nurse, "They told me the last time I was at the clinic that I had Chlamydia, but I stopped taking the antibiotic after 3 days because I felt better." What potential neonatal disorder transmitted during birth most concerns the nurse because of the inadequate treatment? 1 Thrush 2 Syphilis 3 Ophthalmia neonatorum 4 Neurologic complications

3 Chlamydia trachomatis transmitted from the mother usually manifests in the infant as an eye infection; it becomes apparent on the third or fourth postnatal day. Monilia albicans, not Chlamydia trachomatis, causes thrush. Syphilis is acquired transplacentally, not by way of the genital tract. In newborns, ophthalmic or respiratory complications, not neurologic complications, occur with exposure to Chlamydia trachomatis.

A 37-year-old woman agrees to have a prenatal test done to diagnose fetal defects. There is a history of Down syndrome in her family, and this is her first pregnancy. Which invasive prenatal test provides the earliest diagnosis and rapid test results? 1 Nonstress test 2 Amniocentesis 3 Chorionic villus sampling 4 Percutaneous umbilical blood sampling

3 Chorionic villus sampling may be performed between 10 and 12 weeks' gestation. Amniocentesis may be performed after 14 weeks' gestation, when sufficient amniotic fluid is available. Direct access to the fetal circulation with percutaneous umbilical blood sampling may be performed during the second and third trimesters. The nonstress test, which is not invasive, is a technique used for antepartum evaluation of the fetus; it does not reveal fetal defects.

rimigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show. She and her partner attended childbirth preparation classes. Vaginal examination reveals that the cervix is dilated 3 cm and 75% effaced. The fetus is at +1 station in occiput anterior position, and the membranes are intact. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. In light of the nurse's observations regarding the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond? 1 "I can't make a decision on that; I'll have to ask your health care provider." 2 "Please stay in bed; walking could interfere with effective uterine contractions." 3 "It's all right for you to walk as long as you feel comfortable and your membranes are intact." 4 "You may sit in a chair, because your contractions cannot be timed when you walk and I won't be able to listen to the baby's heart."

3 Contractions become stronger and more regular when the woman is standing; also, as the woman walks the diameter of the pelvic inlet increases, allowing easier entrance of the head into the pelvis. Judging from the information gleaned during the admitting assessment the nurse is qualified to make this decision. The contractions of true labor are enhanced when the mother walks. Timing and Doppler auscultation of the fetal heart rate may be continued even if the client chooses to walk.

man calls the prenatal clinic to ask the nurse when he should bring his wife to the hospital. He says, "The baby is due in 2 weeks, but she thinks it could be earlier. This is our first baby, and we're nervous." The nurse knows that as a nullipara, it would be important for the client to be seen if the contractions: 1 Decrease when the client walks 2 Are irregular and vary in intensity 3 Come every 5 minutes for an hour 4 Come every 10 minutes for an hour

3 Contractions every 5 minutes apart for 1 hour are an indication of true labor. Because the woman is a nullipara, this is an appropriate response. Contractions coming 10 minutes apart for 1 hour in a nullipara are too far apart for true labor. This reading would be appropriate for a multiparous woman, whose labor is likely to be shorter and more intense. Contractions that ease when the client walks or are irregular and vary in intensity are signs of false labor.

A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease? 1 Handling a cat litter box 2 Drinking contaminated water 3 Having sex with many partners 4 Eating inadequately cooked meat

3 Cytomegalovirus has been recovered from semen, vaginal secretions, urine, feces, and blood; it is commonly found in clients who are HIV positive. Toxoplasmosis can be contracted from contaminated cat litter. Contaminated water is associated with hepatitis type A. Toxoplasmosis can be contracted from inadequately cooked meat.

A nurse assessing a newborn elicits a positive response on the Ortolani test and as a result suspects that the newborn has developmental dysplasia of the hips (DDH). Which clinical finding supports this suspicion? 1 Legs are of equal length 2 Resistance to flexion of the hips 3 Limited ability to abduct either hip 4 Abduction of each hip to form a right angle

3 DDH limits abduction to less than 90 degrees. With DDH, the legs appear to be of unequal length. Flexion of the hips is not affected by DDH. Abduction of each hip to form a right angle is an expected finding in the newborn; maternal hormones cause loosening of ligaments, which allows abduction of each hip to a right angle (90 degrees).

nurse who is observing a sleeping newborn identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL. The nurse concludes that these findings are indicative of: 1 Hypoglycemia 2 Seizure activity 3 Expected adaptations 4 Respiratory distress syndrome

3 During periods of active or irregular sleep, healthy newborns have some twitching movements and irregular respirations; the heart rate, respirations, and blood glucose level are within expected limits. Hypoglycemia in newborns is characterized by a blood glucose level below 40 mg/dL. Twitching is a common finding in healthy neonates; it often occurs with crying or stimulation. There are no signs of respiratory distress syndrome. The newborn respiratory rate ranges between 30 and 60 breaths/min; irregular breathing is expected.

nurse is caring for a client with class III heart disease who is beginning the second stage of labor. For which medical intervention does the nurse prepare the client at this time? 1 Elective cesarean birth to conserve energy 2 Pudendal anesthesia to prevent restlessness 3 Instrument extraction to ease a vaginal birth 4 Intravenous tocolytic medication to weaken contractions

3 Either the use of outlet forceps or vacuum extraction for the second stage of labor helps decrease the workload of the heart during expulsion, thereby facilitating the vaginal birth. Clients with cardiac problems can give birth vaginally when precautionary measures are instituted; it is preferable to avoid the secondary stress that surgery may impose. Epidural anesthesia is preferred because there is no pain and energy is conserved. Tocolytic agents are used to halt preterm labor. The goal is to progress with labor as quickly as possible.

A nurse has just finished reviewing how anesthesia will be used during a vaginal birth for a client with class I heart disease. What type of anesthesia does the client discuss that indicates to the nurse that the teaching was effective? 1 Spinal 2 Inhalation 3 Epidural regional 4 Local perineal filtration

3 Epidural regional anesthesia provides the safest method of pain relief for clients with heart disease. If the client expends more energy than her heart can tolerate, especially during second stage labor, cardiac decompensation may occur. Unless an emergency cesarean birth is needed, spinal anesthesia is unnecessary for clients with class I heart disease who are not experiencing problems. Inhalation anesthesia is not indicated for a vaginal birth for a client with class I heart disease; it may cause respiratory difficulty. Local perineal anesthesia is used when an episiotomy is to be performed and the client has not had anesthesia during labor.

A nurse on the postpartum unit discusses breast care with a client who is formula feeding her newborn. Which statement indicates to the nurse that more teaching is needed? 1 "The discomfort will be better after a couple of days." 2 "I need to ask my husband to bring me my new bra." 3 "Applying heat to my breasts will help ease the discomfort." 4 "Pain medication will help with the pain from engorgement.

3 Heat increases milk flow, so because the client is not breastfeeding this is an undesired outcome; application of cold is recommended to restrict milk flow. More teaching is not indicated if the client notes that engorgement lasts 48 to 72 hours; indicates the need for a tight, supportive brassiere, which will suppress milk production; or remarks that analgesics will help ease, rather than eliminate, the discomfort of engorgement.

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus? 1 Contact precautions are necessary. 2 It occurs during sexual intercourse. 3 It can be acquired during a vaginal birth. 4 Protection is provided by way of maternal immunity

3 Herpes virus infection can be fatal to a newborn, and the infant should be admitted to the neonatal intensive care unit. Although contact precautions are necessary, herpes infection can occur during sexual intercourse, and protection is conferred on the fetus by the mother, these statements are not relevant in meeting the needs of this neonate who has been exposed to herpes virus during the birthing process.

What should the nurse tell a new mother will be delayed until her newborn is 36 to 48 hours old? 1 Vitamin K injection 2 Test for blood glucose level 3 Screening for phenylketonuria 4 Test for necrotizing enterocolitis

3 In 36 to 48 hours the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of a specific liver enzyme, can result in excessive levels of phenylalanine in the bloodstream and brain, resulting in cognitive impairment; early detection is essential to prevent this. The infant will have a vitamin K injection soon after birth to prevent bleeding problems. Blood is withdrawn from the heel soon after birth to test for hypoglycemia. Necrotizing enterocolitis is a disorder that can affect preterm infants. It is not identified with the use of a test.

A client whose membranes have ruptured is admitted to the birthing unit. Her cervix is dilated 3 cm and 50% effaced. The amniotic fluid is clear and the fetal heart rate is stable. What does the nurse anticipate? 1 A prolonged second stage of labor 2 A difficult birth resulting from delayed effacement 3 Birth of the fetus within a day 4 The stimulation of labor with an oxytocin infusion

3 In an uneventful full-term pregnancy, birth usually occurs within 24 hours after membranes have ruptured. If the birth does not occur within this time frame, both the mother and fetus will be exposed to sepsis and labor will probably be stimulated by the health care provider. There is no relationship between ruptured membranes and the second stage of labor. There are no data to indicate that effacement is delayed. Although it may be done eventually, it is too early to anticipate that labor will be stimulated.

A nurse in the prenatal clinic assesses clients for signs of preeclampsia. What sign, other than increased blood pressure, may indicate preeclampsia? 1 Positive nonstress test 2 Negative contraction stress test 3 Weight gain of 6 lb in 1 month 4 Fetal heart rate below 120 beats/min

3 In preeclampsia, renal blood flow and the glomerular filtration rate are decreased, resulting in fluid retention and rapid weight gain. A positive nonstress test and negative contraction stress test each indicate fetal well-being. The fetal heart rate in a healthy fetus ranges from 110 to 160 beats/min.

A 20-year-old woman comes into the clinic after missing her menstrual period 2 weeks ago and says that she suspects that she is pregnant. As the nurse is reviewing her medications, the client says that she is taking isotretinoin (Accutane). The nurse knows that isotretinoin is: 1 Used to suppress hunger in individuals trying to lose weight, so she should stop taking the medication 2 Often used to treat migraines associated with hormonal changes and should be safe for continued use as needed 3 Teratogenic and associated with major fetal malformations, so the client should stop the medication immediately 4 An atypical antipsychotic, and the woman needs to make an immediate appointment with her mental health care provider to discuss alternative medications

3 Isotretinoin (Accutane) is used to treat severe acne that has not responded to other forms of treatment. It is teratogenic, and pregnancy should be avoided by female clients taking the medication. Isotretinoin is not used to treat migraines, is not an antipsychotic, and is not used in a weight-loss program.

A newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. How should the nurse remove the electrode? 1 Giving the electrode a quick jerk 2 Turning the electrode clockwise until it is free 3 Untwisting the wires before pulling the electrode out 4 Twisting the electrode counterclockwise until it is free

4 For the spiral electrode to be removed it must be turned counterclockwise. Quickly jerking the electrode may result in a lacerating injury to the scalp. The electrode is attached by turning it clockwise. It is unnecessary to untwist the wires; the electrode should not be pulled, because this may cause a scalp laceration.

What does the nurse do to elicit the Moro reflex during a newborn assessment? 1 Quickly turns the infant's head to one side 2 Strokes the infant's back alongside the spine 3 Jars the infant's bassinet suddenly but gently 4 Taps the bridge of the infant's nose briskly but lightly

3 Sudden movement causes the startle response (Moro reflex), which begins with extension and abduction of the extremities with a C shape formed by the index finger and thumb, followed by flexion and adduction of extremities and ending with return of the arms to a relaxed position. Quickly turning the infant's head to one side elicits the asymmetric tonic neck reflex, which simulates the fencing position. Stroking the infant's back along the spine elicits trunk incurvation (Galant reflex). Tapping the bridge of the infant's nose briskly but lightly causes the eyes to close tightly. This is the glabellar, not the Moro, reflex.

The membranes of a client who is at 39 weeks' gestation have ruptured spontaneously. Examination in the emergency department reveals that her cervix is dilated 4 cm and 75% effaced, and the fetal heart rate is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival? 1 Settle the client in bed and attach an external fetal monitor. 2 Have the client undress while taking her history from her partner. 3 Introduce the staff nurses to the couple and try to make them feel welcome. 4 Ask the couple to wait in the examining room while notifying the health care provider.

3 The client is in the first stage of labor; she and the fetus were assessed earlier, and both are stable. At this time the priority of care is the establishment of a trusting relationship with the client and her partner. This will help allay their anxiety. Putting the client in bed and attaching an external fetal monitor may be necessary later; however, it is not the priority. The history should be taken from the client as long as she is capable of providing it. Asking the couple to wait in the examining room while notifying the health care provider is not a priority; the provider may have been notified already.

new mother refuses to look at her newborn, who has a severe birth defect. What is the most therapeutic approach by the nurse? 1 Requesting that the family try to distract her 2 Clarifying why she should stop blaming herself for the baby's handicap 3 Reinforcing the explanation of the defect and giving her time to discuss her fears 4 Waiting until she has sufficiently recovered from the stress of birth and then bringing the baby to her again

3 The correct approach allows the expression of feelings and clarifies explanations that probably were not heard or understood because of anxiety. Requesting that the family try to distract her prevents the client from facing the problem, thereby increasing her feelings of loss of control. Clarifying why she should stop blaming herself closes off communication by not allowing free expression of grief and assumes that the client blames herself. Waiting until she has sufficiently recovered from the stress of birth supports avoidance of the reality of the situation; it does not solve the problem.

Two days after birth a neonate's head circumference is 16 inches (40 cm) and the chest circumference is 13 inches (32.5 cm). What does the nurse infer from these measurements? 1 Microcephaly 2 Narrow chest 3 Enlarged head 4 Expected head size

3 The enlarged head may indicate hydrocephalus. Average head circumference in the healthy newborn is 13.2 to 14 inches (33 to 35 cm), about 1 inch (2.5 cm) larger than the chest circumference. Microcephaly indicates that the head is smaller than expected, not larger. The chest circumference of 13 inches (32.5 cm) is expected in a healthy newborn. The head size is not within expected limits; it is too large.

A health care provider determines that a fetus is in a breech presentation. For which complication should the nurse monitor the client? 1 Rapid dilation of the cervix, indicating precipitate labor 2 Stronger contractions, indicating progression of the labor 3 Nonreassuring fetal signs, indicating prolapse of the cord 4 Cessation of contractions, indicating primary uterine inertia

3 The feet or buttocks are not effective in blocking the cervical opening, and the cord may slip through and become compressed. Rapid dilation and precipitate labor are more likely to occur if the fetus is in a cephalic presentation. Stronger contractions, indicating progression of labor, is an expected occurrence. Uterine inertia may result from fatigue or cephalopelvic disproportion and is not related directly to fetal presentation.

While performing a newborn assessment for a male infant after a scheduled cesarean birth, the nurse notes that the infant's head circumference is 4 cm smaller than his chest circumference. What does this finding indicate? 1 It is an expected finding in a male newborn. 2 The infant's chest size is larger than average. 3 The infant's head size is smaller than average. 4 This finding is to be predicted after cesarean birth

3 The head's circumference is usually 2 cm larger than that of the chest; a head circumference 4 cm smaller than the chest may indicate microcephaly. According to growth charts, the range of head circumference for boys is just slightly (1.25 cm) larger than the chest. Molding does not occur with cesarean birth; therefore the head should be about 2.5 cm larger than the chest at birth. The expected ratio of head to chest circumference indicates that the chest is too small, not too large, for the head size.

A nurse in the prenatal clinic is caring for a client with heart disease who is in her second trimester. What hemodynamic change of pregnancy may affect the client at this time? 1 Decreased red blood cell count 2 Gradually increasing size of the uterus 3 Heart rate acceleration in the last half of pregnancy 4 Increase in cardiac output during the third trimester

3 The heart rate increases by about 10 beats/min in the last half of pregnancy; this increase, plus the increase in total blood volume, can strain a damaged heart beyond the point at which it can efficiently compensate. The number of red blood cells does not decrease during pregnancy. The increased size of the uterus is related to the growth of the fetus, not to any hemodynamic change. Cardiac output begins to decrease by the 34th week of gestation.

The nurse teaches a high school sex education class that herpes genitalis infection cannot be cured but that the disease is marked by remissions and exacerbations. What else should the students be taught about this infection? 1 A healthy lifestyle will prevent exacerbations. 2 Once the infection is effectively treated, exacerbations are rare. 3 Although exacerbations occur they are not as severe as the initial episode. 4 The most effective way to prevent exacerbations is to abstain from sexual activity.

3 The initial infection is both local and systemic; exacerbations are milder and localized. Although optimum health habits may limit exacerbations, they will not prevent them. There is no treatment that will limit the number of exacerbations. Exacerbations are precipitated by physical and emotional stress, not by sexual activity.

A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. What should the nurse instruct the client to do? 1 Stop nursing for a few days and allow the nipple to heal. 2 Manually express milk and feed it to the baby in a bottle. 3 Start feedings on the unaffected breast until the affected breast heals. 4 Use a breast shield to keep the baby from making direct contact with the nipple.

3 The most vigorous suckling occurs during the first few minutes of nursing, as the infant suckles on the unaffected breast; later suckling, on the affected breast, is less traumatic. Stopping nursing for several days is unnecessary and will interfere with lactation. Manual expression may not completely empty the breast, interfering with lactation. A breast shield confuses an infant because it requires a different suckling pattern to obtain milk.

A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. A licensed practical nurse/licensed vocational nurse (LPN/LVN) and aide are also working on the unit. Which nursing action is best delegated to the LPN/LVN? 1 Discharge teaching for a client who delivered her third infant girl 2 days ago 2 Delivering a clear-liquid dietary tray to a client who had a cesarean section 4 hours ago 3 Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10 4 The initial assessment of a client who just delivered an 8 lb 12 oz (3970 g) infant over an intact perineum

3 The pain assessment has been performed and the RN will need to evaluate the effectiveness of the pain medication. However, the administration of oral pain medication is within the scope of practice for an LPN/LVN. Initial teaching and assessment are within the scope of practice for only the RN and may only be delegated to another RN. A meal tray may be delivered by an unlicensed person such as an aide or a dietary employee.

The nurse teaches a client who is to undergo amniocentesis that ultrasonography will be performed just before the procedure to determine the: 1 Gestational age of the fetus 2 Amount of fluid in the amniotic sac 3 Position of the fetus and the placenta 4 Location of the umbilical cord and placenta

3 The position of the fetus and placenta is located by means of ultrasonography to help prevent trauma from the needle during the amniocentesis. Although ultrasonography can be used to determine gestational age, this is not its purpose just before an amniocentesis. Determining the amount of fluid in the amniotic sac is not the purpose of ultrasonography just before an amniocentesis. The position of the placenta and fetus, not just the cord and the placenta, is needed for safe introduction of the needle.

A pregnant woman at 39 weeks' gestation arrives in the triage area of the birthing unit, stating that she thinks her "water broke." What should the nurse do first? 1 Auscultate the fetal heart to determine fetal well-being. 2 Perform Leopold's maneuvers to rule out a breech presentation. 3 Check the vaginal introitus for the presence of the umbilical cord. 4 Do a Nitrazine test on the vaginal fluid for verification of ruptured membranes.

3 The priority is assessment for a prolapsed umbilical cord. This is a life-threatening emergency for the fetus and must be ruled out first. Auscultating the fetal heart to determine fetal well-being is done after it has been verified that the umbilical cord is not visible in the vaginal introitus. Performing Leopold's maneuvers and performing a Nitrazine test each may be done after fetal well-being has been confirmed; neither is the priority.

A nurse is teaching a prenatal class about the types of pain blocks that provide perineal anesthesia during labor. Which type of pain block should the nurse include in the discussion that will provide perineal anesthesia but allow the client to feel contractions and push during the second stage of labor? 1 Saddle 2 Epidural 3 Pudendal 4 Paracervical

3 The pudendal block relieves vaginal and perineal pain but does not impair the ability to push during the second stage of labor. The saddle block relieves pain from the umbilicus to the lower perineum and inner thigh; the client may have difficulty pushing during the second stage of labor. The epidural block relieves pain from the umbilicus to the midthigh; the client may have difficulty pushing during the second stage of labor. The paracervical block relieves uterine pain; it does not relieve perineal pain.

Which criterion should a nurse use when assessing the gestational age of a preterm infant? 1 Simian creases 2 Reflex stability 3 Breast bud size 4 Fingernail length

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

A 20-year-old woman is admitted to the labor and delivery unit after reporting that she is experiencing severe contractions. She is 38 weeks +2 days' gestation. External fetal monitoring is started. During the assessment the nurse notes that the woman is sweating profusely sweating, has dilated pupils and irregular respirations, is hypertensive, and continues to complain of very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. What should the nurse suspect? 1 Heroin abuse 2 Marijuana use 3 Cocaine abuse 4 alcohol withdrwal

3 These signs are seen in pregnant women who abuse cocaine. Yawning, diaphoresis, rhinorrhea, restlessness, and excessive tearing are seen in heroin abuse. Chronic redness in the eyes, drowsiness, forgetfulness, and an unusual odor on the clothing or breath are signs of marijuana use. Anxiety, nervousness, shakiness, and slow speech are seen with alcohol withdrawal. The possibility of seizure activity must also be considered.

An amniotomy is performed to stimulate labor in a client at 42 weeks' gestation. Place the nursing care actions in their order of priority. 1. Checking the fetal heart rate tracings 2. Evaluating the client for signs of an infection 3. Inspecting the perineum for umbilical cord prolapse 4. Assessing the characteristics of the amniotic fluid

3142 As fluid gushes from the amniotic sac, it may carry the umbilical cord out of the birth canal before the presenting part. The nurse should check for this occurrence first because it is an emergency and, if it occurs, immediate intervention will be necessary to prevent fetal harm.

A 37-year-old client with type 1 diabetes and good glycemic control is pregnant for the third time. Her first child is 4 years old, and her second pregnancy resulted in a stillbirth. She is seen in the antepartum testing unit for a nonstress test (NST) at 33 weeks' gestation. What are the primary risk factors in the client's history that indicate a need for the NST? Select all that apply. 1 Age greater than 35 years 2 The risk for placenta previa 3 The risk for placental insufficiency 4 A history of stillbirth from her last pregnancy 5 Maternal history of hypertension

345 Pregnant women with diabetes are prone to placental insufficiency, which can threaten fetal well-being. In addition, history of stillbirth is also an indication for NST. In addition, maternal conditions that can affect placental perfusion such as hypertension is an indication for a NST. Advanced maternal age alone is not an indicator for an NST; although advanced maternal age increases the risk of placenta previa, it is not the primary reason for having an NST.

all women of childbearing age are advised to include at least 400 micrograms of folic acid in the daily diet to lessen the risk of neural tube defects in pregnancy. What should the nurse recommend to meet the recommendation? Select all that apply. 1 Vitamin A 2 Vitamin B6 3 Vitamin B9 4 Vitamin B12 5 Legumes, dark-green leafy vegetables, and citrus fruits 6 Eggs, meat, and poultry

35 Vitamin B9 is folic acid, and legumes, dark-green leafy vegetables, and citrus fruits are natural sources of folic acid. Most women receive adequate vitamin A in their diets, and too much may cause birth defects. Vitamin B6 aids in metabolism conversion and the formation of red blood cells. Vitamin B12 is associated with nerve cells and red blood cells. Eggs, meat, and poultry are sources of vitamin B12.

nurse is caring for a client during the transition phase of labor. The nurse determines that the client has entered the second stage of labor when: 1 There is restlessness and thrashing about. 2 There are complaints of sudden and intense back pain. 3 The client reports that she feels the urge to move her bowels. 4 The client asks for medication to relieve pain from the strong contractions.

3During the second stage the presenting part is low in the birth canal and may cause strong sensations of pressure on the rectum; at this time the cervix is fully dilated and the urge to push is great. Restlessness and thrashing about usually begins during the transition phase of the first stage of labor. Complaints of sudden, intense back pain may occur with persistent posterior pressure; usually the pain does not have a sudden onset. Asking for medication to relieve pain from the strong contractions usually occurs during the active phase of the first stage of labor.

A nurse is reviewing the obstetric history of a client who had an abruptio placentae. What prenatal condition does the nurse expect the client to have had? 1 Cardiac disease 2 Hyperthyroidism 3 Gestational hypertension 4 Cephalopelvic disproportion

3Hypertension during pregnancy leads to vasospasm; this in turn causes the placenta to tear away from the uterine wall (abruptio placentae). Generally cardiac disease does not cause abruptio placentae. Hyperthyroidism may cause an endocrine disturbance in the infant but does not affect blood supply to the uterus. Cephalopelvic disproportion may affect the birth of the fetus but does not affect the placenta.

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at −1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse do next? 1 Teach the client how to push with each contraction. 2 Encourage the client to perform patterned, paced breathing. 3 Provide the client with comfort measures used for women in labor. 4 Prepare to have the client's blood typed and crossmatched in the event of the need for a transfusion.

3The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation. The client is in early first-stage labor; pushing commences during the second stage. Patterned, paced breathing should be used in the transition phase, not the early phase of the first stage of labor. There is no evidence that the client's bleeding is excessive.

The nurse concludes that a couple with a newborn with Erb's palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion? 1 "Surgery will correct the palsy." 2 "This is a progressive disorder with no cure." 3 "Recovery usually occurs in about 3 months." 4 "Physical therapy will be necessary for 1 year

3The nerves that are stretched take about 3 months to recover from the trauma sustained during birth. Passive range-of-motion exercise and intermittent splinting performed by a trained family member will help facilitate recovery. Only in rare instances, when avulsion of the nerves results in permanent damage, is orthopedic or surgical intervention necessary. The paralysis is not progressive, and the prognosis usually is excellent. Physical therapy is necessary for about 3 months, not a year.

A nurse gently performs Leopold maneuvers on a client with a suspected placenta previa. What does the nurse expect from this assessment? 1 Firm engagement of the fetal head 2 Difficulty palpating small fetal parts 3 A high, floating fetal presenting part 4 A hard and tetanically contracted uterus

3With a low-implanted placenta (placenta previa) the presenting part may have difficulty entering the pelvis. Engagement is difficult with a low-lying placenta. Placenta previa does not make it difficult to palpate small fetal parts. A uterus that is hard and tetanically contracted is found in abruptio placentae.

A 23-year-old primigravida is at her first prenatal appointment today. Ultrasound indicates that she is at 9 weeks' gestation. She asks when she can first expect to feel her baby move. The best response by the nurse is: 1 "You should be able to feel the baby move any day now." 2 "You should feel your first light movement of the baby around 24 weeks." 3 "Most women can first detect movement of their babies by 12 to 14 weeks." 4 "Many women are able to first feel light movement between 18 and 20 weeks.

4

A nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first? 1 Notify the practitioner. 2 Elevate the head of the bed. 3 Reposition her on her left side. 4 Administer oxygen by way of facemas

4

A nurse is assessing a newborn's respiratory rate. What clinical findings indicate that the rate is within the expected range? 1 Regular, thoracic, 40 to 60/min 2 Irregular, thoracic, 30 to 60/min 3 Regular, abdominal, 40 to 50/min 4 Irregular, abdominal, 30 to 60/min

4

The hepatitis B-positive mother of an infant born earlier in the day wants her infant to receive the hepatitis B immune globulin (HBIG) vaccine. What is the proper dosage of this vaccine? 1 1.0 mL subcutaneously before discharge 2 0.5 mL subcutaneously within 24 hours of birth 3 1.0 mL intramuscularly within 24 hours of birth 4 0.5 mL intramuscularly within 12 hours of birth

4

The nurse is conducting an initial assessment of a recently delivered newborn. Which assessment requires immediate action by the nurse? 1 Heart rate of 140 beats/min 2 Respirations of 40 breaths/min 3 Breath sounds with fine crackles 4 Expiratory grunting and nasal flaring

4

What should a nurse take into consideration when estimating a preterm newborn's gestational age? 1 Length at birth 2 Rooting and suckling ability 3 Presence of a tonic neck reflex 4 Size of breast tissue and genitali

4

postpartum client is scheduled to have a tubal ligation. She has asked that her husband not be told about the procedure because she has told him that she is having exploratory surgery. The client's husband asks the nurse why his wife needs to have exploratory surgery. How should the nurse respond? 1 "What has the physician told you?" 2 "I don't know the answer to that question." 3 "I'm not allowed to give you that information." 4 "Have you talked to your wife about your concern

4

A nurse is assessing a newborn with congenital toxoplasmosis. What clinical finding does the nurse expect to identify on assessment? 1 Reddish areas on the head 2 Serosanguineous nasal discharge 3 One leg shorter than the other leg 4 Chest circumference larger than head circumferenc

4 A chest circumference larger than the head circumference is microcephaly; this is one sign of congenital toxoplasmosis. If the head circumference is ½ inch to 1 inch (1 to 2 cm) less than the chest circumference, microcephaly is considered. Reddish areas on the head are telangiectatic nevi (also called stork bites), found in some newborns; they are benign and do not require treatment. A serosanguineous nasal discharge is a sign of congenital syphilis called snuffles. One leg that is shorter than the other leg is a sign of developmental dysplasia of the hip and is unrelated to toxoplasmosis.

Ten minutes after administering nalbuphine (Nubain) via IV piggyback to a primigravida in active labor, the nurse notes a fetal heart rate of 132 with minimal variability. The client states that the pain is more tolerable and she is able to use her breathing techniques more effectively. Contractions continue every 2 to 3 minutes and are of 60 seconds' duration. What is the nurse's next action? 1 Reposition the client on the left side to increase placental perfusion. 2 Administer oxygen via mask to minimize apparent fetal compromise. 3 Have an opioid antagonist available to be administered to the infant at the time of birth. 4 Document the findings, including the stable fetal heart rate variability after administering the opioid infusion.

4 A common side effect of an opioid analgesic is decreased fetal heart rate variability. Because the fetal heart rate and the length and duration of the contractions remain stable and the analgesic appears to be effective, the only nursing action is to document the findings. Repositioning the client is not necessary because the data do not indicate decreased placental perfusion. It is not necessary to administer oxygen because the data do not indicate fetal compromise. Naloxone (Narcan), an opioid antagonist, may need to be administered to the newborn, but the present data do not indicate that this is necessary.

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with: 1 A stethoscope at 4 weeks 2 A fetoscope at 10 to 12 weeks 3 Doppler ultrasound after 20 weeks 4 Doppler ultrasound at 10 to 12 weeks

4 A fetal heartbeat can be obtained at 10 to 12 weeks with electronic Doppler ultrasound. The heartbeat cannot be obtained with a stethoscope, and 4 weeks is too early to hear a fetal heart. A fetoscope cannot pick up the heartbeat until the 17th week. The heart rate can be detected 8 to 10 weeks earlier than 20 weeks.

A newborn male is admitted to the nursery. He weighs 10 lb 2 oz, which is 2 lb more than the birthweight of any of his siblings. What should the nurse do in relation to the baby's weight? 1 Document the findings. 2 Place him in a heated crib. 3 Delay starting oral feedings. 4 Perform serial glucose readings

4 A large newborn may be the result of gestational diabetes; it is necessary to check the neonate for hypoglycemia because maternal glucose is no longer available. The nurse should do more than document the findings; the health care provider should be notified after the serial glucose readings are taken. Placing the infant in a heated crib is indicated if the temperature is low and the newborn needs additional warmth. The infant may be hypoglycemic and require the glucose in an oral feeding immediately.

A nurse is caring for a client whose contraction stress test result (CST) is positive. The nurse remains with the client and continues to assess the fetal and maternal monitor strips. What complication does the nurse anticipate? 1 Preeclampsia 2 Placenta previa 3 Fetal prematurity 4 Uteroplacental insufficiency

4 A positive CST result is indicative of a compromised fetus; late decelerations during contractions are associated with uteroplacental insufficiency. Preeclampsia does not cause a positive CST result. A CST is contraindicated for a client with a suspected placenta previa because the contractions may cause bleeding. A CST is contraindicated for a client with a suspected preterm birth or a gestation less than 33 weeks' duration because the contractions may induce true labor.

While caring for a woman who has had a positive contraction stress test (CST), what complication does the nurse suspect? 1 Preeclampsia 2 Placenta previa 3 Imminent preterm birth 4 Uteroplacental insufficiency

4 A positive contraction stress test (CST) indicates a compromised fetus with late decelerations during contractions; this is associated with uteroplacental insufficiency. Preeclampsia does not cause a positive CST unless the fetus is compromised. Ultrasonography demonstrates placenta previa; a CST is contraindicated because it may induce labor. A CST is contraindicated for a woman with a suspected preterm birth or a pregnancy of less than 33 weeks' gestation because it may induce labor.

On her first visit to the prenatal clinic a woman is to have a pelvic examination. What information should the nurse include when discussing the examination? 1 She should direct her questions to the health care provider. 2 She should relax during the examination to prevent discomfort. 3 A douche will be necessary before the examination for the biopsy. 4 A rectal examination may be performed after the pelvic examination

4 A rectal examination is usually is conducted to palpate any masses or detect abnormalities in the rectum; it is performed after the vaginal examination to avoid contamination. Gloves are changed between vaginal and rectal examinations. The client should be encouraged to ask questions of both the health care provider and the nurse so that nursing care and treatment plans based on client needs can be developed. The client may be unable to relax and will feel powerless if told that she must do so. Douching or vaginal irrigation is contraindicated unless specifically prescribed; there are no data to indicate that there will be a biopsy.

A few hours after being admitted to the hospital with a diagnosis of inevitable abortion, a client at 16 weeks' gestation begins to experience a bearing-down sensation and suddenly expels the products of conception in bed. What should the nurse do first? 1 Notify the health care provider. 2 Administer the prescribed sedative. 3 Take the client to the operating room. 4 Check the client's fundus for firmness

4 After a spontaneous abortion the uterine fundus should be palpated for firmness, which indicates effective uterine tone. If the uterus is not firm or appears to be hypotonic, hemorrhage may occur; a soft or boggy uterus also may indicate retained placental tissue. The nurse would notify the health care provider if necessary after checking for fundal firmness. Administering the prescribed sedative is not the priority; the potential for hemorrhage must be monitored. Taking the client to the operating room is unnecessary; fetal and placental contents are small and expelled easily.

On the third postpartum day a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged? 1 There is an overabundance of milk. 2 Breastfeeding is probably ineffective. 3 The breasts have been inadequately supported. 4 The lymphatic system in the breasts is congested

4 An exaggeration of venous and lymphatic circulation caused by prolactin occurs before lactation. Effective breastfeeding does not prevent engorgement; a lag between the production of milk and the efficiency of the ejection reflex often causes engorgement. Engorgement occurs before lactation or milk production. Inadequately support of the breasts does not cause engorgement, but support may relieve some of the discomfort.

24-year-old client who has been told that she is pregnant is at her first prenatal visit. She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan regarding her daily caloric intake include? 1 100 more calories during the first trimester 2 540 more calories during the third trimester 3 300 more calories during the three trimesters 4 340 more calories during the second trimester

4 An extra 340 calories per day during the second trimester is the recommended caloric increase for adult women who are of average weight; this increase will meet the nutritional needs of both fetus and mother during the second trimester. The caloric intake during the first trimester should be about the same as in the nonpregnant state. The increase in caloric intake should be about 460 calories in the third trimester. Caloric needs, as well as caloric intake, vary from trimester to trimester, depending on fetal/maternal energy needs.

A nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication? 1 Persistent diarrhea 2 Decreased abdominal circumference 3 Small amount of vomitus after each gastric feeding 4 Increased amount of residual gastric volume from earlier feedings

4 An increasing residual volume without increasing intake indicates that absorption is decreasing, a sign of NEC. Diarrhea may or may not be related to NEC. The abdominal circumference increases, not decreases, with NEC. Small amounts of vomitus (spitting up) are common in the neonate because the cardiac (lower esophageal) sphincter of the stomach is weak.

A client is admitted to the birthing unit in active labor. What should the nurse expect after amniotomy is performed? 1 Diminished bloody show 2 Increased and more variable fetal heart rate 3 Less discomfort with contractions 4 Progressive dilation and effaceme

4 Artificial rupture of the membranes (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater because contractions usually increase in intensity and frequency after amniotomy.

A nurse is caring for a client in labor. What assessment finding reveals that the transition phase of labor has probably begun? 1 The client assumes the lithotomy position. 2 The frequency of contractions decreases. 3 The client complains of back and perineal pain. 4 The client begins to perspire and has a flushed face.

4 As cervical dilation nears completion, labor is intensified, resulting in an increase in energy expenditure; this increase manifests in perspiration and a flushed face. The client is usually restless and thrashes about during transition, assuming no particular position. Back pain usually indicates a posterior-lying position of the fetus's head. Perineal pain starts during the second stage of labor. Pain is increased because contractions are more frequent and intense and they last longer.

A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response? 1 "An oxytocic." 2 "An analgesic." 3 "A corticosteroid." 4 "A beta-adrenergic.

4 Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily. Other tocolytics that may be used are magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers. Oxytocin is a hormone that is secreted by the posterior pituitary gland; it stimulates contractions and is released after birth to initiate the let-down reflex. Analgesics do not halt preterm labor. Corticosteroids do not halt labor; they are used during preterm labor to accelerate fetal lung maturity, when birth is likely to occur within 24 to 48 hours.

A newborn has just begun to breastfeed. Although the neonate has latched on to the mother's nipple, soon after beginning to suck the infant begins to choke, has an excessive quantity of frothy secretions, and exhibits unexplained episodes of cyanosis. How should the nurse intervene? 1 Tell the client to use the other breast and continue breastfeeding. 2 Delay the feeding to allow more time for the infant to recover from the birthing process. 3 Contact the lactation consultant to help the client learn a more successful breastfeeding technique. 4 Halt the feeding and notify the health care provider to evaluate the infant for a tracheoesophageal fistula.

4 Choking, frothy secretions, and episodes of cyanosis are signs of a tracheoesophageal fistula. Oral feedings must be stopped until further evaluation can be accomplished. Continued intake of fluids may result in aspiration. Rest is not the concern. There are no data to indicate that the mother is using inadequate breastfeeding techniques.

mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant? 1 "Because he tires easily, it's best to have him lying in bed while he is being fed." 2 "Hold him in a horizontal position and feed him slowly to help prevent aspiration." 3 "Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion." 4 "Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air.

4 Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements.

Within minutes of giving birth to a healthy infant, the client displays symptoms of respiratory distress. An amniotic fluid embolism is suspected. In addition to respiratory distress, for what other complication should the nurse assess the client? 1 Hypertension 2 Uterine atony 3 Thrombophlebitis 4 Uncontrolled bleeding

4 Disseminated intravascular coagulation is associated with amniotic fluid embolism; both problems may occur after premature separation of the placenta. Hypotension, not hypertension, is expected. Uterine atony usually is not associated with amniotic fluid embolism. Thrombophlebitis is not a complication of amniotic fluid embolism.

The nurse is providing care to a client with preeclampsia who is receiving magnesium sulfate 2 g/hr. The nurse receives a call from the laboratory technician indicating that the client has a magnesium level of 6.4 mEq/L. What is the next nursing action? 1 Stopping the infusion 2 Assessing the client's deep tendon reflexes 3 Assessing the client's level of consciousness 4 Documenting the level in the client's electronic medical record

4 Documentation of the magnesium level on the fetal monitoring strip can serve as a point of correlation between the blood level and a decrease in fetal activity or fetal heart rate reactivity, which is common in a client receiving magnesium sulfate. There is no indication that the infusion of magnesium sulfate needs to be stopped. Although the magnesium level is well above the normal range of 1.7 to 2.2 mg/dL, the therapeutic range for magnesium for the preeclamptic client is 4 to 7.5 mEq/L, or 5 to 8 mg/dL. The nurse must constantly assess the client for a toxic level of magnesium, which can depress the central nervous system and slow the respiratory rate, alter the level of consciousness, and cause deep tendon reflexes to diminish or disappear. These manifestations generally appear after the magnesium level is above 8 mg/dL; respiratory arrest is associated with a level above 10 mg/dL.

An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home? 1 Visibility of the sclerae above the irises 2 Violent involuntary muscle contractions 3 Excessive fluid accumulation in the abdomen 4 Fever accompanied by decreased responsiveness

4 Fever accompanied by decreased responsiveness is associated with infection. This is the greatest postoperative hazard for children with shunts for hydrocephalus. Violent involuntary muscle contractions may occur as the result of an infected shunt; however, it is not the most common sign of an infectious process. Eyes with sclerae visible above the irises occur with progressively increasing intracranial pressure, usually before shunt insertion. The peritoneum absorbs cerebrospinal fluid adequately; ascites is not a problem.

A newborn is Rh-positive, and the mother is Rh-negative. The infant is to receive an exchange transfusion. The nurse explains to the parents that their baby will receive Rh-negative blood because: 1 It is the same as the mother's blood. 2 It is neutral and will not react with the baby's blood. 3 The possibility of a transfusion reaction is eliminated. 4 The red blood cells will not be destroyed by maternal anti-Rh antibodies

4 Giving Rh-positive cells will lead to further hemolysis; Rh-negative cells are not attacked by maternal antibodies in the infant's blood. Blood cells usually do not come from the mother. Rh-negative blood is not neutral; it provides a temporary safeguard from further hemolysis. A reaction to other antigens in the crossmatched blood may occur.

hen checking a newborn's reflexes, the nurse is unable to elicit one reflex response that is often absent in neonates born vaginally in the breech presentation. How should the nurse attempt to elicit this response? 1 Moving the thumb along the sole of the foot 2 Stroking the ulnar surface of the hand and fifth finger lightly 3 Touching the skinfold of the mouth and cheek on the same side 4 Holding the infant in the upright position while pressing the feet flat on the crib mattres

4 Holding the infant in the upright position while pressing the feet flat on the crib mattress elicits the stepping response, which is absent when paresis is present and in neonates born vaginally in the breech presentation. Moving the thumb along the sole of the foot should elicit the Babinski reflex, which is unrelated to a vaginal breech birth. Stroking the ulnar surface of the hand and fifth finger lightly should elicit the digital response reflex, which is unrelated to a vaginal breech birth. Touching the skinfold of the mouth and cheek on the same side should elicit the rooting response reflex, which is unrelated to a vaginal breech birth.

While a multiparous client is in active labor her membranes rupture spontaneously, and the nurse notes a loop of umbilical cord protruding from her vagina. What is the priority nursing action? 1 Monitoring the fetal heart rate 2 Covering the cord with a saline dressing 3 Pushing the cord back into the vaginal vault 4 Holding the presenting part away from the cord

4 Holding the presenting part away from the cord must be done immediately to maintain cord circulation and prevent the fetus from becoming anoxic. The priority is maintaining cord circulation; although monitoring is important, it does not alter the emergency. Keeping the cord moist is secondary; keeping pressure off the cord is the priority. The cord should not be touched, because this increases pressure on the cord, further reducing oxygen flow to the fetus.

A nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of potential interventions for the neonate. What is the priority intervention? 1 Promoting bonding 2 Preventing infection 3 Supporting temperature 4 Maintaining respirations

4 If the airway is not patent and gas exchange is inadequate, life cannot be sustained; therefore maintaining respirations is the priority. Although bonding is important to the parent-child relationship, without oxygen life is not sustained. Although body temperature is important because the preterm neonate is lacking brown fat and other defense mechanisms needed to maintain temperature, without oxygen life is not sustained.

A multigravida has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time? 1 In the pelvic cavity 2 Just below the xiphoid process 3 At the umbilicus and in the right quadrant 4 Halfway between the symphysis pubis and the umbilicus

4 Immediately after birth the fundus is palpated midway between the symphysis pubis and the umbilicus. The gradual descent of the uterus into the pelvic cavity takes about 2 weeks after the birth. The fundus is never elevated to the level of the xiphoid process. The fundus is not to the level of the umbilicus until 1 hour after birth; when the uterus is deviated to the right, it usually indicates bladder distention.

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant? 1 Increased Po2 2 Lowered HCO3 3 Decreased Pco2 4 Decreased blood pH

4 In addition to increased Pco2, hypoxia from inadequate oxygen/carbon dioxide exchange leads to anaerobic metabolism with an accumulation of acid by-products; both lower blood pH. Po2 is decreased because inadequate lung surface area is available for diffusion of gases. Acidosis, not alkalosis, is present; bicarbonate will be normal or increased in the body's attempt to compensate. Pco2 increases because inadequate lung surface area is available for the diffusion of gases.

Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion? 1 Facial redness and an urge to push 2 Bulging perineum, crowning, and caput 3 Less intense, less frequent contractions 4 Increased bloody show, irritability, and shaking

4 Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. Bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor.

On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of: 1 Breast milk ingestion 2 Inadequate fluid intake 3 Immaturity of the vascular system 4 Breakdown of fetal red blood cells

4 Physiological jaundice is caused by an increased bilirubin level, a result of the breakdown of fetal red blood cells, which the immature liver cannot conjugate rapidly enough for excretion; this occurs on the second or third day of life. Breast milk jaundice does not occur until the fifth or sixth postpartum day; it is believed to be caused by a factor in the breast milk that inhibits conjugation of bilirubin. Inadequate fluid intake is evidenced by a decreased urinary output and depressed fontanels. Mottling in the newborn is related to an immature vascular system.

The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding? 1 They are obstructed sebaceous glands. 2 They are excessive superficial capillaries. 3 The cause is a decreased vitamin K level in the newborn. 4 The cause is an increased intravascular pressure during birth

4 Pressure exerted during the birth process causes increased intravascular pressure, which may result in petechiae caused by capillary rupture. Obstructed sebaceous glands are milia, which are white, not red. Superficial capillaries are intact capillaries. They are distinguished from petechiae if they disappear when the area is blanched. Bloody stools or oozing from the umbilicus is the most common sign of vitamin K deficiency, not red pinpoint dots on an infant's face and neck.

A nurse is caring for several preterm infants. What precautions should the nurse take to limit the risk for retinopathy of prematurity (retrolental fibroplasia)? 1 Monitoring phototherapy and lowering the temperature 2 Controlling environmental temperature and humidity 3 Maintaining the prescribed oxygen concentration and increasing the amount of humidity 4 Keeping oxygen at the lowest concentration necessary and discontinuing it as soon as it is feasible

4 Prolonged oxygen administration at a relatively high concentration in a preterm infant whose retinas are incompletely differentiated or vascularized may result in retinopathy of prematurity (ROP, retrolental fibroplasia). Capillary overgrowth in the retinas and vitreous bodies may result, causing capillary hemorrhage, fibrosis, and retinal detachment. Phototherapy is used to decrease hyperbilirubinemia; it is unrelated to retinopathy of prematurity. Temperature and humidity are not factors in the development of ROP. Although the oxygen concentration should be maintained in accordance with the infants needs, humidity will not influence the development of ROP.

A nurse is caring for a preterm infant who is receiving oxygen therapy. What should the nurse do in an attempt to prevent retinopathy of prematurity (ROP)? 1 Cover the neonate's eyes with a shield. 2 Place the neonate in an elevated side-lying position. 3 Assess the neonate every hour with a pulse oximeter. 4 Support the neonate's saturation while providing minimal FiO2.

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

A nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect? 1 Bulging perineum 2 Pinkish vaginal discharge 3 Crowning of the fetal head 4 Rectal pressure during contractions

4 Rectal pressure occurs at the beginning of the transition phase of labor when the fetal head starts to press on the rectum during contractions. The perineum bulges when transition is complete and the cervix is fully dilated. Pink vaginal discharge occurs when labor begins, not at the beginning of the transition phase. The fetal head crowns at the end of the second stage, shortly before birth.

A postpartum client is changing her female newborn's diaper, sees what appears to be red-tinged mucus on the diaper, and calls the nursing station for assistance. What nursing intervention is necessary? 1 Notifying the pediatrician 2 Collecting and sending a sample to the lab 3 Monitoring diapers to see whether this continues 4 Explaining that this is a normal reaction to the mother's hormones

4 Secretion of red-tinged mucus by a newborn, called pseudomenstruation, is the result of prenatal influence by some of mother's hormones. It should last no longer than a few weeks. It is not necessary to call the physician, because this is a normal reaction to the mother's hormones. Monitoring diapers is not necessary, and no sample needs to be collected.

A newborn is found to have neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care? 1 Administering an opioid antagonist 2 Limiting fluid intake to inhibit vomiting 3 Assessing for age-appropriate developmental level 4 Reducing environmental stimuli to promote relaxation

4 The addicted neonate is very sensitive to lights, noise, and surrounding activities; the infant must be kept calm and comfortable to reduce overreaction to stimuli. Morphine or other opioids are administered to those infants who have loose stools and other gastrointestinal problems resulting from withdrawal. Some of these infants need tranquilizers or sedatives to minimize the effects of withdrawal. Fluid intake must be increased to prevent dehydration in the infant who vomits. Assessment for developmental status is not the priority; physical needs take precedence. An opioid antagonist would lower the seizure threshold and is contraindicated in this clinical situation.

A postpartum nurse is providing care to four maternal/infant couplets. After receiving handoff report from the off-going nurse, which client will the nurse see first? 1 The term infant with a heart rate of 158 beats/min 1 hour after birth 2 The mother who has saturated one peripad over the 4 hours since delivery 3 The mother with a white blood cell count of 12,500/mm3 24 hours after delivery 4 The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL 12 hours after birth

4 The appearance of jaundice during the first 24 hours of life or persistence beyond the ages delineated usually indicates a potential pathologic process that requires further investigation. The white blood cell count increase is normal after birth, possibly a result of to stress and tissue trauma during the birthing process. The acceptable range for the newborn heart rate is 110 to 160 beats/min. Saturating more than one pad per hour with lochia rubra is a matter of concern because it is less than the acceptable limit.

A vaginal examination reveals that a client's cervix is 90% effaced and dilated 6 cm. The fetus's head is at station 0 and the fetus is in an ROA position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor? 1 Early first stage of labor 2 Transition stage of labor 3 Beginning second stage labor 4 Midway through first stage of labor

4 The cervix is 90% effaced and dilated 6 cm during the active phase of the first stage of labor. When the cervix is dilated 6 cm, the individual is beyond the early stage of labor. Transition is not a stage of labor; it is the last phase of the first stage of labor, which begins when the cervix is dilated 8 cm. The second stage of labor begins when the cervix is fully dilated and 100% effaced.

A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. What should the nurse instruct the client to do? 1 Take slow, deep breaths. 2 Hold her breath and push with each contraction. 3 Breathe faster than usual with long cleansing breaths. 4 Pant and then exhale through the mouth with pursed lips

4 The client cannot bear down when panting and exhaling. The objective is to control the birth and prevent injury to both mother and newborn. The nurse should place a hand on the perineum to apply gentle pressure and then support the head as it emerges. Slow breaths enhance relaxation; this type of breathing is impossible to achieve when the fetal head is crowning. Holding the breath and pushing will result in a precipitous birth that could cause injury to both mother and newborn. Breathing faster than usual and taking long cleansing breaths are impossible to achieve when the fetal head is crowning.

A nurse is caring for a client in the transition phase of labor. What breathing pattern should the nurse instruct the client to use when there is an urge to push at 9 cm of dilation? 1 Expulsion pattern 2 Slow-paced pattern 3 Shallow-chest pattern 4 Panting-blowing pattern

4 The client should use a panting or blowing pattern to overcome the premature urge to push. Expulsion breathing should not be used at this time because the cervix is not fully dilated and cervical edema and lacerations may occur. A slow-paced pattern or shallow-chest pattern is ineffective during the transition phase of labor; these patterns are used during early labor.

A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss? 1 Viral or bacterial infection 2 Obstructive gastrointestinal anomaly 3 Generalized muscle response to stimulation 4 Imbalance between nutrient intake and fluid loss

4 The newborn's intake of milk is gradual and small, and at the same time there is loss of extracellular fluid, primarily in the form of stool and urine. A 5% weight loss is not uncommon after birth; other signs more commonly support the presence of a viral or bacterial infection or an obstructive gastrointestinal anomaly. A generalized muscle response to stimulation is not the cause of the weight loss.

What should the nurse do to help parents proceed with bonding behaviors immediately after birth? 1 Assess for typical parenting techniques. 2 Demonstrate desired behaviors to the parents. 3 Postpone footprinting the newborn until later in the day. 4 Delay applying the antibiotic to the newborn's eyes

4 The parents need an opportunity for close eye-to-eye contact during the first hour after birth. Prophylactic eye medications may irritate the newborn's eyes, preventing them from opening. Assessment is appropriate but will not facilitate parent-newborn bonding; favorable conditions for bonding should be provided before assessment. The nurse should assess, not demonstrate, behavior at this time. Footprinting should be done immediately to ensure proper identification of the newborn.

The health care provider hands a neonate to a nurse immediately after birth. What should the nurse do next for the newborn? 1 Perform an abbreviated physical assessment. 2 Administer oxygen until cyanosis disappears. 3 Cut the umbilical cord and attach an umbilical clip. 4 Dry and provide skin-to-skin contact with the mothe

4 The priority is preventing heat loss; drying the newborn prevents heat loss through evaporation, and skin-to-skin contact with the mother provides a warm environment while promoting attachment. These actions conserve the newborn's oxygen and glycogen reserves. Performing an abbreviated physical assessment is important but not a priority; assessment should be delayed until the infant is warm. Administering oxygen until cyanosis disappears is not necessary because warming the infant will reduce cyanosis if there is no respiratory obstruction. Cutting the umbilical cord and attaching an umbilical clip may be done after provisions have been made to prevent heat loss.

The priority nursing intervention when the membranes rupture spontaneously is an assessment of: 1 Cervical dilation and effacement 2 The amount, color, and odor of fluid 3 Frequency and duration of contractions 4 Variable decelerations or fetal bradycardia

4 The priority nursing intervention when the membranes rupture is to detect the possibility of cord compression or prolapse, which would be evidenced by variable decelerations or fetal bradycardia. Although assessing the amount, color, and odor of amniotic fluid is a necessary intervention, determining the fetus's status is more important. Assessing the cervical status and the contractions will not provide any data about fetal well-being.

Which client should a nurse suspect is at increased risk for postpartum hemorrhage? 1 One who breastfeeds in the birthing room 2 One who receives a pudendal block for the birth 3 One whose third stage lasts less than 10 minutes 4 One who gives birth to an infant weighing 9 lb 8 oz

4 The risk for a postpartum hemorrhage is greater with large infants because the uterine musculature has been stretched excessively, thus impairing uterine contractions after the birth. Early breastfeeding stimulates uterine contractions and lessens the chance of hemorrhage. Having a pudendal block for the birth does not contribute to the risk for postpartum hemorrhage, because the anesthetic for a pudendal block does not affect uterine contractions. A third stage of labor lasting less than 10 minutes is a short third stage; a prolonged third stage of labor, 30 minutes or longer, could lead to postpartum hemorrhage.

A nurse is assessing a postpartum client for signs of an impending hemorrhage resulting from laceration of the cervix. Besides monitoring the client for a firm uterus, what other assessment is important? 1 Slowed pulse rate 2 Increased blood pressure 3 Persistent muscular twitching 4 Continuous trickling of blood

4 The trickling of blood indicates continuous bleeding. Close monitoring is required and intervention will be necessary if signs of hemorrhagic shock appear. The pulse becomes very rapid, but not until a significant amount of blood is lost. Blood pressure is normotensive; it usually does not drop significantly until a large amount of blood has been lost. Persistent muscular twitching is not a sign of impending hemorrhage.

A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infant's skin appears yellow. What is the most likely cause? 1 Neonatal sepsis 2 Rh incompatibility 3 Physiologic jaundice 4 ABO incompatibility

4 There is an apparent ABO incompatibility because the mother is O and the infant is B; incompatibility can cause jaundice within the first 24 hours. The information provided does not indicate neonatal sepsis. Rh incompatibility is not a factor because the mother is Rh positive. Jaundice in the first 24 hours is not physiologic; it is pathologic.

Five minutes after being born, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings? 1 Cerebral palsy 2 Neonatal syphilis 3 Fetal alcohol syndrome 4 Opioid drug withdrawa

4 These adaptations indicate opioid drug withdrawal; the infant should be monitored for further withdrawal signs during the first 24 hours after birth. Signs of cerebral palsy usually manifest later in infancy. A low-grade fever and copious serosanguineous discharge from the nose are signs of syphilis. Growth deficiencies in length, weight, and head circumference are associated with fetal alcohol syndrome, as are certain facial abnormalities.

In her 37th week of gestation, a client with type 1 diabetes has amniocentesis to determine fetal lung maturity. The lecithin/sphingomyelin ratio is 2:1, phosphatidylglycerol is present, and creatinine is 2 mg/dL. What conclusion should the nurse draw from this information? 1 A cesarean birth will be scheduled. 2 A birth must take place immediately. 3 The fetus need not be monitored any longer. 4 The newborn should be free from respiratory problems.

4 These test results confirm fetal lung maturity, and the neonate should be free of major respiratory problems. They do not indicate the need for a cesarean birth. There is no indication of fetal compromise; an immediate vaginal or cesarean birth is not necessary. Further fetal monitoring will be necessary in the future, as with any pregnancy.

A health care provider plans to perform a vaginal examination of a client with a partial placenta previa. What should the nurse have available when this examination is performed? 1 1 unit of freeze-dried plasma 2 Vitamin K and a syringe for injection 3 Heparin sodium for intravenous infusion 4 2 units of typed and crossmatched blood

4 Vaginal examination in a patient with placenta previa may result in sudden, severe hemorrhage because of the location of the placenta near the cervical os; whole blood should be ready for administration to prevent shock. Because of this possible complication, a sonogram is preferred to vaginal examination. Fresh, not freeze-dried, plasma is used to restore coagulation factors after severe blood loss. Adults manufacture their own vitamin K, and an injection will not help prevent bleeding from the placenta. Administration of heparin sodium is contraindicated in the presence of hemorrhage.

During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of varicose veins. In light of this information, what should the nurse's assessment include? 1 Monitoring daily clotting times 2 Assessing for peripheral pulses 3 Monitoring daily hemoglobin values 4 Assessing for signs of thrombophlebiti

4 Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.

A client who is having a difficult labor is found to have cephalopelvic disproportion. Which medical order should the nurse question? 1 Maintain NPO status. 2 Start peripheral IV of ¼ NS. 3 Record fetal heart tones every 15 minutes. 4 Piggyback another 10-unit bag of oxytocin (Pitocin

4 When there is cephalopelvic disproportion, a cesarean birth is indicated; infusing oxytocin (Pitocin) at this time could result in fetal compromise and uterine rupture. The nothing-by-mouth (NPO) status is appropriate in anticipation of a cesarean birth. A peripheral IV is needed not only for hydration but also for venous access if IV medications become necessary. The client probably has an electronic monitor recording the fetal heart rate and uterine contractions; the findings of these assessments should be documented regularly in accordance with hospital protocol.

A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. Folic acid is important for this client because it: 1 Lessens sickling of RBCs 2 Prevents vaso-occlusive crises 3 Decreases cellular oxygen need 4 Compensates for a rapid turnover of red blood cells

4Folic acid is needed to produce heme for hemoglobin .Supplementation with folic acid does not reduce sickling, and it will not prevent vaso-occlusive crisis. Adequate oxygenation and hydration help prevent vaso-occlusive crisis (painful episode). There is no change in needs; sickling decreases the oxygen-carrying capacity of hemoglobin.

t 30 weeks' gestation a client with class II cardiac disease expresses concern about her labor and asks the nurse what to expect. What does the nurse tell the client to expect if cardiac decompensation occurs? 1 Elective cesarean birth 2 Artificial rupture of the membranes 3 Induction of labor with an oxytocin infusion 4 Epidural anesthesia with a vacuum extraction bir

4Regional anesthesia does not compromise cardiovascular function as it provides pain relief. Vacuum extraction limits the mother's pushing during the second stage of labor, thereby limiting the workload of the heart and conserving energy. Major surgery is performed on clients with cardiac problems only when absolutely necessary because surgery adds additional stress to a compromised heart. Artificial rupture of the membranes may or may not be done; it is not specific to women with cardiac disease. Induced labor often is more stressful and painful than natural labor.

The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect? 1 Cerebral palsy 2 Neonatal syphilis 3 Fetal alcohol syndrome 4 Opioid drug withdrawa

4These signs are indicative of withdrawal from an opioid with typical changes occurring in the central nervous system; the newborn should be monitored during the first 24 to 48 hours. The signs of cerebral palsy usually manifest later in infancy. The signs of syphilis are a low-grade fever and a copious serosanguineous discharge from the nose. The signs of fetal alcohol syndrome are growth deficiencies in length, weight, and head circumference, plus distinctive facies.