Maternity Exam 1 NCLEX Qs
A laboring woman is lying in the supine position. The most appropriate nursing action is to: a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure. d. Determine whether there is fetal tachycardia.
a. may cause heavy uterus to put pressure on the vena cava. reducing blood to her heart. relieved by having her turn to one side.
A client at 37 weeks' gestation gives birth to a healthy boy. When inspecting her newborn in the birthing room the client becomes concerned and asks, "What's this sticky white stuff all over him?" How should the nurse respond? 1. "It's a secretion from the baby's fat cells and is called milia." 2. "This is vernix. It helps protect the baby while he's in the uterus." 3. "Your baby was born several weeks early and we expect to see this." 4. "It's nothing to be concerned about. Most newborns are covered with it."
. 2 A factual response will allay the mother's concern. Vernix caseosa is a cheesy white substance that covers the fetus. Vernix caseosa protects the fetus from the amniotic fluid while in utero; most of it disappears by 40 weeks' gestation. 1 Milia are white pinpoint dots (sebaceous glands) on the newborn's nose, chin, and forehead that disappear within a few weeks. 3 The nurse should explain only what vernix is; referring to the infant as preterm may unnecessarily alarm the mother. 4 This is not answering the mother's question nor is it abundant on neonates born at term. Mosbys NCLEX review
Which measure would be least effective in preventing postpartum hemorrhage? 1) Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered 2) Encourage the woman to void every 2 hours 3) Massage the fundus every hour for the first 24 hours following birth 4) Teach the woman the importance of rest and nutrition to enhance healing
3 The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.
The nurse is caring for a client who is in the taking-in phase of the postpartum period. The area of health teaching that the client will be most responsive to is: 1. Perineal care 2. Infant feeding 3. Infant hygiene 4. Family planning
1 During the taking-in phase a woman is primarily concerned with being cared for and being cared about. 2 This is best taught during the taking-hold phase of postpartum adjustment. 3 This is best taught during the taking-hold phase of postpartum adjustment. 4 This is not a primary concern during the immediate postpartum period. Mosbys NCLEX review
What must the nurse assess first when planning to promote mother-infant attachment? 1. Mother-infant interaction 2. Mother-father interaction 3. The infant's physical status 4. The mother's ability to care for her infant
1 The extent and quality of the mother-infant interaction is believed to be a predictor of positive or negative attachment behaviors. 2 Although this is assessed, it is not as significant as mother-infant interaction. 3 Although this is assessed, it is not as significant as mother-infant interaction. 4 Although this is assessed, it is not as significant as mother-infant interaction. Mosbys NCLEX review
A postpartum adolescent mother confides to the nurse that she hopes her baby will be good and sleep through the night. What should the nurse plan to teach the client to do? 1. Talk softly and cuddle her baby when crying occurs 2. Keep her baby awake for longer periods during the day 3. Ensure sleep by adding cereal to her baby's bedtime bottle 4. Put a soft and brightly colored toy next to her baby at bedtime
1 The mother needs to learn the realities of infant behaviors and how to cope with them; holding and talking to her infant are consoling measures. 2 It is unhealthy to disrupt a neonate's sleep pattern. 3 The infant is too young to be given cereal. 4 At this age a toy is not meaningful and is an inadequate substitute for parental attention. Mosbys NCLEX review
The husband of a woman who had her fourth child 3 weeks ago states she has been irritable and crying since bringing her newborn home. The nurse tries to assist him in understanding the situation by stating that: 1. Having four children is tiring and assistance may be needed 2. His wife probably has postpartum blues and it will soon pass 3. This behavior is common after birth and he should not be too concerned 4. Women often express themselves by crying and he should allow her to continue
1 This statement acknowledges the situation and suggests a possible solution to the problem. 2 Postpartum blues occurs earlier; this may be postpartum depression and should not be dismissed lightly. 3 This response is not only false reassurance, but it does not address the problem that is evident in the situation. 4 This is stereotyping and nontherapeutic. Mosbys NCLEX review
During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting-go b. Taking-in c. Taking-on d. Taking-hold
A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. In the taking-in phase, the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment. During the taking-hold phase, the mother assumes responsibility for her own care and shifts her attention to the infant
Which anticipatory guidance action by the nurse makes role transition to parenthood easier? a. Helps the new parents identify resources b. Recommends employing babysitters frequently c. Tells the parents about the realities of parenthood d. Offers a home phone number and tells parents to call if they have a question
A Available resources within the community can assist the parents in role transition. Some parents may not be able to afford babysitters. Also, this removes them from the parenthood role. Each adult sees parenthood in a different light. They cannot be compared. Searching out resources for the parents is an important task. However, the nurse should not give her personal number to clients.
A nurse is instructing a client to cough and deep breathe after an emergency cesarean birth. The client says, "Get out of here. Don't you know that I am in pain?" Which response is most effective? 1. "I'm sure you are in pain. I'll come back later." 2. "If you are unable to cough, try to take six very deep breaths." 3. "Your pain is to be expected, but you must exercise your lungs." 4. "I'll give you something for your pain. We can start the coughing tomorrow."
2 This is important because deep breathing aids in fully expanding the alveoli and prevents stasis of pulmonary secretions. 1 This postpones needed pulmonary exercises, which may result in atelectasis and retained respiratory secretions. 3 This response avoids the problem; it states a fact and does not allow the client a sense of control. 4 Although this response is empathic, it postpones needed pulmonary exercises, which may compromise the client's respiratory status Mosbys NCLEX review
New parents are asked to sign the consent for their son to be circumcised. They ask for the nurse's opinion of the procedure. How should the nurse respond? 1. "You should talk to the physician about this if you have any questions." 2. "Let's talk about it because there are advantages and disadvantages." 3. "It is a safe procedure and it is best for male infants to be circumcised." 4. "Although it may be a somewhat painful experience for the baby, I would allow it if I were you."
2 This response permits exploration of the parents' wishes and leads to assisting them in making their own decision. 1 This response blocks further discussion; the nurse can answer some of the questions and refer those that cannot be answered to the practitioner. 3 This is a value judgment; it denies the parents' right to decide. 4 This response might frighten the parents; it denies the parents their power of decision. Mosbys NCLEX review
When the 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed, the nurse's most helpful response is: a. "Stop breastfeeding until the infection clears." b. "Pump the breasts to continue milk production, but do not give breast milk to the infant." c. "Begin all feedings with the affected breast until the mastitis is resolved." d. "Breastfeeding can continue unless there is any abscess formation."
ANS: D The woman with mastitis can continue to breastfeed unless an abscess forms.
A client who had a cesarean birth seems upset. She has been having difficulty breastfeeding for 2 days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action? 1. Obtaining the requested formula 2. Administering the prescribed pain medication 3. Assessing the client's breastfeeding technique 4. Notifying the practitioner of the client's request to switch feeding methods
3 The nurse should assess the client to determine why she is having difficulty with breastfeeding. She may be uncomfortable or in need of assistance with her breastfeeding technique. 1 Immediately providing the formula without assessing the situation does not meet the client's needs at this time. 2 Pain may be a factor in the client's frustration with breastfeeding, but this should be determined as a result of the assessment process. 4 This is premature. It is the nurse's responsibility to assess the situation and arrive at a solution in collaboration with the client. Mosbys NCLEX review
When performing external cardiac massage on a 28-week gestation neonate, the nurse should: a. Compress the chest 80 times a minute b. Alternate massage with ventilation c. Use the palm of the hand for massage d. Compress the sternum half the depth of the anterior-posterior (A/P) diameter of the chest
ANS B Compressions (massage) and ventilations should be alternated to ensure both adequate breathing and circulation. Two fingers should be used to compress the chest approximately one-third the A/P diameter of the chest at a rate of 100 to 120 times per minute.
Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? 1. Retained placental fragments 2. Urinary tract infection 3. Cervical laceration 4. Uterine atony
3. Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting. Retained placental fragments and uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected. UTI won't cause vaginal bleeding, although hematuria may be present.
A nurse notes that a mother has neurofibromatosis. The nurse should assess the neonate for: a. Acrocyanosis b. Café au lait spots c. Hemangiomas d. Port wine nevus
ANS B Neonatal café au lait spots are associated with maternal neurofibromatosis. Acrocyanosis is the normal bluish color of the extremities on some neonates immediately after birth. The other conditions are not associated with any preexisting maternal conditions.
What common concern of the mother after an unexpected cesarean birth should the nurse anticipate? 1. Postoperative pain 2. Prolonged period of hospitalization 3. Inability to assume the mothering role 4. Sense of failure in the birthing process
4 An unplanned cesarean birth can result in guilt, disappointment, anger, and a sense of failure as a woman. 1 This is not usually a common concern. 2 The hospital stay is not exceptionally prolonged; the client usually is discharged within 2 to 4 days. 3 Mothers who have had a cesarean birth can assume the mothering role to the same degree as women who have had a vaginal birth. Mosbys NCLEX review
Which of the following complications can be potentially life threatening and can occur in a client receiving a tocolytic agent? 1. diabetic ketoacidosis 2. hyperemesis gravidarum 3. pulmonary edema 4. sickle cell anemia
3. pulmonary edema Tocolytics are used to stop labor contractions. The most common adverse effect associated with the use of these drugs is pulmonary edema. Clients who dont have diabetes dont need to be observed for diabetic ketoacidosis. Hyperemesis gravidium doesnt result from tocolytic use. Sickle cell anemia is an inherited genetic condition and doesnt develop spontaneously
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: 1.Tell the woman she can rest after she feeds her baby 2.Recognize this as a behavior of the taking-hold stage 3.Record the behavior as ineffective maternal-newborn attachment 4.Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
4. Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby
Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching? 1. The vaccine is safe in clients with egg allergies 2. Breast-feeding isn't compatible with the vaccine 3. Transient arthralgia and rash are common adverse effects 4. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects
4. The client must understand that she must not become pregnant for 3 months after the vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs so an allergic reaction may occur in clients with egg allergies. The virus is not transmitted into the breast milk, so clients may continue to breastfeed after the vaccination. Transient arthralgia and rash are common adverse effects of the vaccine.
You're assessing the five minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 97, no response to stimulation, flaccid, absent respirations, cyanotic throughout. What is your patient's APGAR score and what nursing interventions who perform based on the APGAR score?
A: 0 P: 1 G: 0 A: 0 R: 0 Answer: APGAR 1; full resuscitation measures (Your baby's first hours of life | womenshealth.gov.)
Metabolic screening of an infant reveals an elevated phenylketonuria (PKU) level. Which statement indicates that the parents understand this disease? a. "This disease will eventually result in mental retardation." b. "Meat and milk will need to be avoided." c. "My infant can be fed normally until they begin to eat solid foods." d. "By age 2, most children outgrow this condition."
ANS B Phenylketonuria involves the body's inability to metabolize the amino acid phenylalanine, which is a common molecule in meat, milk and eggs. Normal intelligence can be obtained if a strict low-phenylalanine diet is maintained through adolescence. Parents should consult a dietician to ensure nutritive requirements are being met.
While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses both a firm uterine fundus and a trickle of bright blood. The nurse is: a. concerned and reports a probable cervical laceration. b. attentive and massages the uterus to expel retained clots. c. distressed and reports a possible clotting disorder. d. satisfied with the normal early postpartum finding.
ANS: A The bright trickle of blood with a firm uterus suggests a cervical laceration.
The nurse determines that a woman with mastitis understands treatment instructions when she says she will: a. "Apply cold compresses to the painful areas." b. "Take a warm shower before nursing the baby." c. "Nurse first on the affected side." d. "Empty the affected breast every 8 hours."
ANS: B Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.
If massage and breastfeeding is ineffective in controlling a boggy uterus, the nurse explains that the physician may order: a. ritodrine. b. magnesium sulfate. c. oxytocin. d. bromocriptine.
ANS: C Oxytocin (Pitocin) is the most common drug ordered to control uterine atony as it stimulates uterine contractions.
Fran delivered a 9 lb, 10 oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch diameter puddle of blood. What is your first action? a. Call for help b. Assess the fundus for firmness c. Take her blood pressure d. Check the perineum for lacerations
B Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated.
A 35 year old female is currently pregnant with twins. She has 10 year old triplets who were born at 32 weeks gestation, and 16 years old who was born at 41 week gestation. Twelve years ago she had a miscarriage at 8 weeks gestation. What is her GTPAL?
Answer: G=4, T=1, P=1, A=1, L=4
When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary
C Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life
A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A) Ankle clonus in noted B) The blood pressure decreases C) Seizures do not occur D) Scotomas are present
C) Seizures do not occur For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Ankle clonus indicated hyperreflexia and may precede the onset of eclampsia. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure. Nurselabs
To promote bonding and attachment immediately after birth, which action should the nurse take? a. Assist the mother in feeding her baby. b. Allow the mother quiet time with her infant. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in assuming an en face position with her newborn.
D Assisting the mother in assuming an en face position with her newborn will support the bonding process. After birth is a good time to initiate breastfeeding, but first the mother needs time to explore the new infant and begin the bonding process. The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time. The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time.
A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: A) Assess for hypovolemia and notify the health care provider B) Begin hourly pad counts and reassure the client C) Begin fundal massage and start oxygen by mask D) Elevate the head of the bed and assess vital signs
D Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.
The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to: a. Tell the mother she must pay attention to her infant. b. Show the mother how the infant initiates interaction and pays attention to her. c. Demonstrate for the mother different positions for holding her infant while feeding. d. Arrange for the mother to watch a video on parent-infant interaction.
b. Show the mother how the infant initiates interaction and pays attention to her.
The nurse recognizes that an expected change in the hematologic system that occurs during the 2nd trimester of pregnancy is: A) A decrease in WBC's B) In increase in hematocrit c) An increase in blood volume D) A decrease in sedimentation rate.
c) An increase in blood volume The blood volume increases by approximately 40-50% during pregnancy. The peak blood volume occurs between 30 and 34 weeks of gestation. The hematocrit decreases as a result of the increased blood volume Nurselabs
A pregnant client is making her first Antepartum visit. She has a two year old son born at 40 weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the nurse should identify that the client is: A) G4 T3 P2 A1 L4 B) G5 T2 P2 A1 L4 c) G5 T2 P1 A1 L4 D) G4 T3 P1 A1 L4
c) G5 T2 P1 A1 L4 5 pregnancies; 2 term births; twins count as 1; one abortion; 4 living children. Nurselabs
The best way for the nurse to promote and support the maternal-infant bonding process is to: a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods.
c. we want to have close and frequent interaction between baby and mom. best facilitated by rooming in helping her identify her feelings is helpful but not the first priority
After giving birth to a healthy infant boy, a primiparous woman, 16 years old, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is Risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman's discharge, what should the nurse be certain to include in the plan of care? a. Instruct the patient how to feed and bathe her infant. b. Give the patient written information on bathing her infant. c. Advise the patient that all mothers instinctively know how to care for their infants. d. Provide time for the patient to bathe her infant after she views an infant bath demonstration.
d. Provide time for the patient to bathe her infant after she views an infant bath demonstration. Having the mother demonstrate infant care is a valuable method of assessing the client's understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child.
Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the client in emptying her bladder.
d. urinary retention can cause distention of the bladder. which will lift and displace uterus it will go up and right. this intervention needs to be done before we notify doc. if we do the intervention and she still is distended then we need to call doc. and then do fundal massage.
Rho (D) immune globulin (RhoGAM) is prescribed for a woman following delivery of a newborn infant and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following? A) Being affected by Rh incompatibility B) Having Rh positive blood C) Developing a rubella infection D) Developing physiological jaundice
A) Being affected by Rh incompatibility Rh incompatibility can occur when an Rh-negative mom becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the baby's Rh positive blood can enter the maternal circulation, causing the woman's immune system to form antibodies against Rh positive blood. Administration of Rho(D) immune globulin prevents the woman from developing antibodies against Rh positive blood by providing passive antibody protection against the Rh antigen. Nurselabs
A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A) Connect the resuscitation bag to the oxygen outlet B) Turn on the apnea and cardiorespiratory monitors C) Set up the intravenous line with 5% dextrose in water D) Set the radiant warmer control temperature at 36.5* C (97.6*F)
A) Connect the resuscitation bag to the oxygen outlet The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.
A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? A) Document the findings B) Contact the physician C) Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D) Reinforce the dressing
A) Document the findings yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment.
A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of a Goodell's sign. The nurse determines this sign indicates: A) softening of the cervix B) A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus. C) The presence of hCG in the urine D) The presence of fetal movement
A) softening of the cervix In the early weeks of pregnancy the cervix becomes softer as a result of increased vascularity and hyperplasia, which causes the Goodell's sign. Nurselabs
Select all of the physiological maternal changes that occur during the PP period. A) Cervical involution occurs B) Vaginal distention decreases slowly C) Fundus begins to descend into the pelvis after 24 hours D) Cardiac output decreases with resultant tachycardia in the first 24 hours E) Digestive processes slow immediately
A,C After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor Nurselabs
Question 1: You're collecting the 1 minute APGAR on a male newborn. You note the heart rate to be 140 bpm. The baby's cry is strong and regular and the body is pink with slightly blue hands. There is some flexion of arms and legs. While assessing the newborn it moves and cries. What is the newborn's APGAR score?
A: 1 P: 2 G: 2 A: 1 R: 2 Answer: APGAR: 8 (Your baby's first hours of life | womenshealth.gov.)
A septic preterm infant's IV infiltrated. While attempting to obtain new IV access, the nurse should monitor the infant carefully for: a. Hypoglycemia b. Hyperkalemia c. Fever e. Circulatory collapse
ANS A Preterm infants use glucose as their primary source of energy, especially when any infectious process is present. Sudden halt to a glucose source, such as the infiltration of an IV, can cause significant hypoglycemia. While the other conditions are important to watch for during septic events, they are not the primary concern at this time.
Standard commercial infant formulas contain 20 calories per ounce. An infant was fed 45 mL at each of eight feedings in a 24-hour period. How many calories did this infant receive? a. 160 b. 240 c. 360 d. 900
ANS B An ounce contains 30 mL, therefore this infant consumed 1.5 ounces, or 30 calories' worth, at each feeding. 30 calories multiplied by 8 feedings equals a total of 240 calories consumed by the infant in the 24-hour period
Which statement indicates that the mother needs additional teaching following circumcision of her newborn son? a. "It's okay if the petroleum gauze falls off in the diaper." b. "I'll leave the gauze in place for 24 hours." c. "I can use water to gently remove any yellow crusting that may form." d. "I don't need to worry about a little oozing of blood from the site."
ANS C Yellow crusting is indicative of scar formation, and should not be disturbed, as that may increase risk of bleeding. Petroleum gauze should remain in place for 24 hours, but if it falls off in the diaper, then it should not be replaced. After the original gauze falls off, plain petroleum jelly should be applied with each diaper change for 48 hours following the procedure. A few drops of oozing blood is normal in the first 24 hours, but bleeding that is more than minor or persists after 24 hours should be reported.
A neonate has received 8 hours of phototherapy for hyperbilirubinemia. The nurse should notify the health care provider if which of the following is noted? a. Discolored skin b. Maculopapular skin rash c. Urine specific gravity of 1.008 d. Absent Moro reflex
ANS D An absent Moro reflex can indicate bilirubin encephalopathy, a rare but life-threatening condition. Copper-colored skin discoloration and maculopapular skin rash can be normally associated with phototherapy. Normal neonatal urine specific gravity ranges between 1.001 and 1.020.
A post-term neonate, weighing 4.1 kg (9 lb, 1 oz) with Apgar scores of 8 at 1 minute and 9 at 5 minutes following cesarean delivery, is exhibiting tremors of the hands and feet, and an increased respiratory rate. Which nursing diagnosis would be a priority? a. Hyperthermia related to use of radiant warmer b. Decreased cardiac output related to cesarean delivery c. Ineffective airway clearance related to post-term gestational age d. Imbalanced nutrition: Less than body requirements related to depleted glycogen stores
ANS D Large infants require higher caloric intake to maintain their glycogen stores. Symptoms of hypoglycemia can include limb tremors and tachypnea. No evidence exists that this infant is having difficulty clearing his airway, or experiencing hyperthermia. Decrease cardiac output is not indicated in this scenario.
The nurse instructs a primaparous client about bottle-feeding her newborn infant. Which of the following demonstrates that the client understands the instructions? a. Burps the infant after 1 ounce (oz) of formula b. Placing three-fourths of the bottle nipple into the infant's mouth c. Pointing the nipple toward the infant's palate d. Placing the infant on his back after feeding
ANS D Laying an infant on his back after feeding is recommended to reduce the incidence of sudden infant death syndrome (SIDS). The mother should burp the infant after ½ oz of formula and again after the infant has finished eating to reduce risk of regurgitation. The entire nipple should be used, and pointed directly into the mouth, not angled toward the palate.
The nurse conducting a childbirth preparation class warns the patients that shock, a real threat after delivery, is caused by what factor(s)? Select all that apply. a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage
ANS: B, C, D, E Hypertension is not a cause for postpartum shock; all other options can cause shock
In order to reduce the risk of mastitis, what will the nurse teach a nursing mother to do? Select all that apply. a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying.
ANS: B, C, D, E Nursing mothers should take in about 3 liters of fluid a day. All other options are interventions to reduce the risk of mastitis and milk accumulation in the breast.
A woman has had persistent lochia rubra for two weeks after her delivery and is experiencing pelvic discomfort. When subinvolution is diagnosed, the nurse explains that the usual treatment for this disorder is: a. uterine massage. b. oxytocin infusion. c. dilation and curettage. d. hysterectomy.
ANS: C Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall.
The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. To prevent thrombus formation the nurse would: a. have the woman sit in a chair for meals. b. monitor vital signs every 4 hours and report any changes. c. tell the woman to remain in bed with her legs elevated. d. assist the woman with ambulation for short periods of time.
ANS: D Early ambulation and range-of-motion exercises are valuable aids to preventing thrombus formation in the postpartum woman.
The best response to a postpartum woman who tells the nurse that she feels "tired and sick all of the time since I had the baby 3 months ago" is: a. "This is a normal response for the body after pregnancy. Try to get more rest." b. "I'll bet you will snap out of this funk real soon." c. "Why don't you arrange for a babysitter so you and your husband can have a night out?" d. "Let's talk about this further. I am concerned about how you are feeling."
ANS: D If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive.
The term reciprocal attachment behavior refers to which of the following? a. Behavior during the sensitive period when the infant is in the quiet alert stage b. Positive feedback an infant exhibits toward parents during the attachment process c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents
B In this definition, reciprocal refers to the feedback from the infant during the attachment process. The quiet alert state is a good time for bonding but does not define reciprocal attachment. Reciprocal attachment deals with feedback behavior and is not unidirectional.
When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A) Document the findings B) Notify the physician C) Reassess the client in 2 hours D) Encourage increased intake of fluids
B Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician. Nurselabs
After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product? A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia
B The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood
The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? A) Obtain hemoglobin and hematocrit levels B) Instruct the mother to request help when getting out of bed C) Elevate the mother's legs D) Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheaded and dizziness have subsided
B Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order. Nurselabs
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells the nurse that she doesn't have any history of abortion or fetal demise. The nurse would document the GTPAL for this client as: A) G= 3, T = 2, P = 0, A = 0, L =1 B) G = 2, T = 0, P = 1, A = 0, L =1 C) G = 1, T = 1. P = 1, A = 0, L = 1 D) G= 2, T= 0, P = 0, A = 0, L = 1
B) G = 2, T = 0, P = 1, A = 0, L =1 Pregnancy outcomes can be described with the acronym GTPAL. "G" is Gravidity, the number of pregnancies. "T" is term births, the number of born at term (38 to 41 weeks). "P" is preterm births, the number born before 38 weeks gestation. "A" is abortions or miscarriages, included in "G" if before 20 weeks gestation, included in parity if past 20 weeks AOE. "L" is live births, the number of births of living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 37 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1. Nurselabs
The nurse decides on a teaching plan for a new mother and her infant. The plan should include: A) Discussing the matter with her in a non-threatening manner B) Showing by example and explanation how to care for the infant C) Setting up a schedule for teaching the mother how to care for her baby D) Supplying the emotional support to the mother and encouraging her independence
B) Showing by example and explanation how to care for the infant Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A) Hypotension and Bradycardia B) Tachypnea and retractions C) Acrocyanosis and grunting D) The presence of a barrel chest with grunting
B) Tachypnea and retractions : The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of: A) Two umbilical veins and one umbilical artery B) Two umbilical arteries and one umbilical vein C) Arteries carrying oxygenated blood to the fetus D) Veins carrying deoxygenated blood to the fetus
B) Two umbilical arteries and one umbilical vein Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries. Once oxygenated, the blood then is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus. Nurselabs
A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? A) Complaints of a tearing sensation B) Complaints of intense pain C) Changes in vital signs D) Signs of heavy bruising
C Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? A) Ask the client to turn on her side B) Ask the client to lie flat on her back with the knees and legs flat and straight C) Ask the mother to urinate and empty her bladder D) Massage the fundus gently before determining the level of the fundus.
C Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm. Nurselabs
A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: A) Subcutaneous injection B) Intravenous injection C) Instillation of the preparation into the lungs through an endotracheal tube D) Intramuscular injection
C) Instillation of the preparation into the lungs through an endotracheal tube The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.
A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: A) Wrap the tape measure around the infant's head and measure just above the eyebrows. B) Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes C) Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes D) Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth
C) Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes To measure the head circumference, the nurse should place the tape measure under the infant's head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included.
A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse? A) Urinary output of 20 ml since the previous assessment B) Deep tendon reflexes of 2+ C) Respiratory rate of 10 BPM D) Fetal heart rate of 120 BPM
C) Respiratory rate of 10 BPM Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is WNL for a resting fetus. Nurselabs
A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. A) Monitor maternal vital signs every 2 hours B) Notify the physician if respirations are less than 18 per minute. C) Monitor renal function and cardiac function closely D) Keep calcium gluconate on hand in case of a magnesium sulfate overdose E) Monitor deep tendon reflexes hourly F) Monitor I and O's hourly G) Notify the physician if urinary output is less than 30 ml per hour.
C,D,E,F,G When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys. Nurselabs
A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds based on the understanding that this most likely is due to which of the following? A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter
D The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? A) Retake the temperature in 15 minutes B) Notify the physician C) Document the findings D) Increase hydration by encouraging oral fluids
D The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: A) One peripad per day B) Two peripads per day C) Three peripads per day D) Eight peripads per day
D The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day. Nurselabs
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A) Negative Coombs test B) Bleeding from the nose and ear C) Jaundice after the first 24 hours of life D) Jaundice within the first 24 hours of life
D The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? A) Retake the temperature in 15 minutes B) Notify the physician C) Document the findings D) Increase hydration by encouraging oral fluids
D The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration. Nurselabs
Which action best explains the main role of surfactant in the neonate? A) Assists with ciliary body maturation in the upper airways B) Helps maintain a rhythmic breathing pattern C) Promotes clearing mucus from the respiratory tract D) Helps the lungs remain expanded after the initiation of breathing
D) Helps the lungs remain expanded after the initiation of breathing Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? A) Sleepiness B) Cuddles when being held C) Lethargy D) Incessant crying
D) Incessant crying A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.
In the 12th week of gestation, a client completely expels the products of conception. Because the client is Rh negative, the nurse must: a) Administer RhoGAM within 72 hours B) Make certain she receives RhoGAM on her first clinic visit C) Not give RhoGAM, since it is not used with the birth of a stillborn D) Make certain the client does not receive RhoGAM, since the gestation only lasted 12 weeks.
a) Administer RhoGAM within 72 hours RhoGAM is given within 72 hours postpartum if the client has not been sensitized already. Nurselabs
A first-time father is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, which point should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak at 5 to 7 mg/dL between the second and fourth days of life. d. This condition is also known as breast milk jaundice.
c. bilirubin of this type peaks at 5 between 2 to 4 days of life. within normal limits patho in 24 hours and is caused by blood incompatibility breast fed is by 2 weeks of life and is caused by breast milk insufficiency.