Maternity Final Exam practice questions

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Match the cluster of neonatal behaviors with the correct level on the NBAS scale. a.Habituation b.Orientation c.Range of state d.Autonomic stability e.Regulation of state 1. Signs of stress related to homeostatic adjustment 2. Ability to respond to discrete stimuli while asleep 3. Measure of general arousability 4. How the infant responds when aroused 5. Ability to attend to visual and auditory stimuli while alert

1. ANS: D DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 2. ANS: A DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 3. ANS: C DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 4. ANS: E DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 5. ANS: B DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

PPH may be sudden and result in rapid blood loss. The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss. Astute assessment of the client's circulatory status can be performed with noninvasive monitoring. Match the type of noninvasive assessment that the nurse would perform with the appropriate clinical manifestation or body system. a.Palpation b.Auscultation c.Inspection d.Observation e.Measurement 1. Pulse oximetry 2. Heart sounds 3. Arterial pulses 4. Skin color, temperature, and turgor 5. Presence or absence of anxiety

1. ANS: E DIF: Cognitive Level: Apply REF: p. 808 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: To perform a complete noninvasive assessment of the circulatory status in postpartum clients who are bleeding, the nurse must perform the following: palpation (rate, quality, equality) of arterial pulses; auscultation of heart sounds or murmurs and breath sounds; inspection of skin color, temperature, and turgor; level of consciousness; capillary refill, neck veins, and mucous membranes; observation of either the presence or absence of anxiety, apprehension, restlessness, and disorientation; and measurement of blood pressure, pulse oximetry, and urinary output. 2. ANS: B DIF: Cognitive Level: Apply REF: p. 808 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: To perform a complete noninvasive assessment of the circulatory status in postpartum clients who are bleeding, the nurse must perform the following: palpation (rate, quality, equality) of arterial pulses; auscultation of heart sounds or murmurs and breath sounds; inspection of skin color, temperature, and turgor; level of consciousness; capillary refill, neck veins, and mucous membranes; observation of either the presence or absence of anxiety, apprehension, restlessness, and disorientation; and measurement of blood pressure, pulse oximetry, and urinary output. 3. ANS: A DIF: Cognitive Level: Apply REF: p. 808 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: To perform a complete noninvasive assessment of the circulatory status in postpartum clients who are bleeding, the nurse must perform the following: palpation (rate, quality, equality) of arterial pulses; auscultation of heart sounds or murmurs and breath sounds; inspection of skin color, temperature, and turgor; level of consciousness; capillary refill, neck veins, and mucous membranes; observation of either the presence or absence of anxiety, apprehension, restlessness, and disorientation; and measurement of blood pressure, pulse oximetry, and urinary output. 4. ANS: C DIF: Cognitive Level: Apply REF: p. 808 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: To perform a complete noninvasive assessment of the circulatory status in postpartum clients who are bleeding, the nurse must perform the following: palpation (rate, quality, equality) of arterial pulses; auscultation of heart sounds or murmurs and breath sounds; inspection of skin color, temperature, and turgor; level of consciousness; capillary refill, neck veins, and mucous membranes; observation of either the presence or absence of anxiety, apprehension, restlessness, and disorientation; and measurement of blood pressure, pulse oximetry, and urinary output. 5. ANS: D DIF: Cognitive Level: Apply REF: p. 808 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: To perform a complete noninvasive assessment of the circulatory status in postpartum clients who are bleeding, the nurse must perform the following: palpation (rate, quality, equality) of arterial pulses; auscultation of heart sounds or murmurs and breath sounds; inspection of skin color, temperature, and turgor; level of consciousness; capillary refill, neck veins, and mucous membranes; observation of either the presence or absence of anxiety, apprehension, restlessness, and disorientation; and measurement of blood pressure, pulse oximetry, and urinary output.

Which behaviors would be exhibited during the letting-go phase of maternal role adaptation? (Select all that apply.) A.Emergence of family unit B.Dependent behaviors C.Sexual intimacy relationship continuing D.Defining one's individual roles E.Being talkative and excited about becoming a mother

A, C, D, Emergence of family unit, sexual intimacy relationship continuing, and defining one's individual roles represent interdependent behaviors associated with the letting-go phase. Dependent behaviors are exhibited in the taking-in phase. Being talkative and excited about becoming a mother represents the taking-hold phase and is an example of dependent-independent behaviors.

Parents can facilitate the adjustment of their other children to a new baby by: A.Having children at home choose or make a gift to give the new baby on his or her arrival home. B.Emphasizing activities that keep the new baby and other children together. C.Having the mother carry the new baby into the home so she can show the other children the baby. D.Reducing stress on the other children by limiting their involvement and care of the new baby.

A. Because the family is an interactive, open unit, the addition of a new family member affects everyone. Siblings have to assume new positions within the family hierarchy. Parents often face the task of caring for a new child while not neglecting others. Having the siblings choose or make a gift for their new brother or sister is a good way for them to feel included. Parents need to distribute their attention in an equitable manner. One way to ensure that this happens is to set aside special time just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so that she can give her full attention to the other children. Children should be actively involved in the care of the baby, according to their ability, without being overwhelmed.

The process in which the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics is called: A.Mutuality. B.Bonding. C.Claiming. D.Acquaintance.

A. Bonding is the process through which over time parents form an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking. Claiming is the process by which parents identify their new baby in terms of likeness to other family members, the differences, and the baby's uniqueness.

Baby-friendly hospitals mandate that infants be put to breast within the first _______ after birth. A. 1 hour B.30 minutes C.2 hours D.4 hours

A. Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the BFHI mandates 1 hour. Four hours is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.

1. The breasts of a woman who is bottle feeding her baby are engorged. The nurse should instruct her to: A. Wear a snug, supportive bra. B. Allow warm water to soothe the breasts during a shower. C. Express milk from breasts occasionally to relieve discomfort. D. Place absorbent pads with plastic liners into her bra to absorb leakage.

A. Wear a snug, supportive bra. Correct A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Ice packs, fresh cabbage leaves, and mild analgesics may also relieve discomfort. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners would keep the nipples and areola moist, leading to excoriation and cracking.

The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action? a.The pediatrician should be notified if the newborn has not voided in 24 hours. b.Breastfed infants will likely void more often during the first days after birth. c.Brick dust or blood on a diaper is always cause to notify the physician. d.Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

ANS: A A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants will void less during this time because the mother's breast milk has not yet come in. Brick dust may be uric acid crystals; blood spotting could be attributable to the withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if the cause of bleeding is not apparent. Weight loss from fluid loss might take 14 days to regain.

A new mother states that her infant must be cold because the baby's hands and feet are blue. This common and temporary condition is called what? a.Acrocyanosis b.Erythema toxicum neonatorum c.Harlequin sign d.Vernix caseosa

ANS: A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and intermittently appears over the first 7 to 10 days after childbirth. Erythema toxicum neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. One half of the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the newborn.

Under which circumstance should the nurse immediately alert the pediatric provider? a.Infant is dusky and turns cyanotic when crying. b.Acrocyanosis is present 1 hour after childbirth. c.The infant's blood glucose level is 45 mg/dl. d.The infant goes into a deep sleep 1 hour after childbirth.

ANS: A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life and is within the normal range for a newborn.Infants enter the period of deep sleep when they are approximately 1 hour old.

Which intervention can nurses use to prevent evaporative heat loss in the newborn? a.Drying the baby after birth, and wrapping the baby in a dry blanket b.Keeping the baby out of drafts and away from air conditioners c.Placing the baby away from the outside walls and windows d.Warming the stethoscope and the nurse's hands before touching the baby

ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation quickly occurs. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold surfaces.

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond? a."Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." b."Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." c."Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." d."Your baby will easily get cold stressed and needs to be bundled up at all times."

ANS: A Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, all newborns in open bassinets should be wrapped to protect them from the cold. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is a loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss; however, this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature.

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" What is the nurse's best response? a."That's meconium, which is your baby's first stool. It's normal." b."That's transitional stool." c."That means your baby is bleeding internally." d."Oh, don't worry about that. It's okay."

ANS: A Explaining what meconium is and that it is normal is an accurate statement and the most appropriate response. Transitional stool is greenish-brown to yellowish-brown and usually appears by the third day after the initiation of feeding. Telling the father that the baby is internally bleeding is not an accurate statement. Telling the father not to worry is not appropriate. Such responses are belittling to the father and do not teach him about the normal stool patterns of his daughter.

Part of the health assessment of a newborn is observing the infant's breathing pattern. What is the predominate pattern of newborn's breathing? a.Abdominal with synchronous chest movements b.Chest breathing with nasal flaring c.Diaphragmatic with chest retraction d.Deep with a regular rhythm

ANS: A In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is also a sign of respiratory distress.

Which condition is considered a medical emergency that requires immediate treatment? a.Inversion of the uterus b.Hypotonic uterus c.ITP d.Uterine atony

ANS: A Inversion of the uterus is likely to lead to hypovolemic shock and therefore is considered a medical emergency. Although hypotonic uterus, ITP, and uterine atony are serious conditions, they are not necessarily medical emergencies that require immediate treatment.

What is the most common reason for late postpartum hemorrhage (PPH)? a.Subinvolution of the uterus b.Defective vascularity of the decidua c.Cervical lacerations d.Coagulation disorders

ANS: A Late PPH may be the result of subinvolution of the uterus. Recognized causes of subinvolution include retained placental fragments and pelvic infection. Although defective vascularity, cervical lacerations, and coagulation disorders of the decidua may also cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a.Babinski b.Tonic neck c.Stepping d.Plantar grasp

ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infant's toes curl over the nurse's finger.

How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma? a.A cephalhematoma may occur with a spontaneous vaginal birth. b.A cephalhematoma only happens as a result of a forceps- or vacuum-assisted delivery. c.It is present immediately after birth. d.The blood will gradually absorb over the first few months of life.

ANS: A The nurse should explain that bleeding between the skull and the periosteum of a newborn may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. Low forceps and other difficult extractions may result in bleeding. However, a cephalhematoma can also spontaneously occur. Swelling may appear unilaterally or bilaterally, is usually minimal or absent at birth, and increases over the first 2 to 3 days of life. Cephalhematomas gradually disappear over 2 to 3 weeks. A less common condition results in the calcification of the hematoma, which may persist for months.

What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating? a.Vernix caseosa b.Surfactant c.Caput succedaneum d.Acrocyanosis

ANS: A The protection provided by vernix caseosa is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

Which component of the sensory system is the least mature at birth? a.Vision b.Hearing c.Smell d.Taste

ANS: A The visual system continues to develop for the first 6 months after childbirth. As soon as the amniotic fluid drains from the ear (in minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.

A perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause for this bleeding? a.Uterine atony b.Uterine inversion c.Vaginal hematoma d.Vaginal laceration

ANS: A Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage; however, it is not the most likely source of this client's bleeding. Further, if the woman were experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding for vaginal hematoma is pain, not the presence of profuse bleeding. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

Which statements regarding physiologic jaundice are accurate? (Select all that apply.) a.Neonatal jaundice is common; however, kernicterus is rare. b.Appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c.Because jaundice may not appear before discharge, parents need instruction on how to assess for jaundice and when to call for medical help. d.Jaundice is caused by reduced levels of serum bilirubin. e.Breastfed babies have a lower incidence of jaundice

ANS: A, B, C Neonatal jaundice occurs in 60% of term newborns and in 80% of preterm infants. The complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to be taught how to evaluate their infant for signs of jaundice. Jaundice is caused by elevated levels of serum bilirubin. Breastfeeding is associated with an increased incidence of jaundice.

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. What are these four essential factors? a.Chemical b.Mechanical c.Thermal d.Psychologic e.Sensory

ANS: A, B, C, E Chemical factors are essential to initiate breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations and results in a drop in the level of prostaglandins, which are known to inhibit breathing. Mechanical factors are also necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. After the birth, the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. The stimulation of these receptors also contributes to the initiation of breathing. Sensory factors include handling by the health care provider, drying by the nurse, lights, smells, and sounds. Psychologic factors do not contribute to the initiation of respirations.

Which statements describe the first stage of the neonatal transition period? (Select all that apply.) a.The neonatal transition period lasts no longer than 30 minutes. b.It is marked by spontaneous tremors, crying, and head movements. c.Passage of the meconium occurs during the neonatal transition period. d.This period may involve the infant suddenly and briefly sleeping. e.Audible grunting and nasal flaring may be present during this time

ANS: A, B, C, E The first stage is an active phase during which the baby is alert; this stage is referred to as the first period of reactivity. Decreased activity and sleep mark the second stage, the period of decreased responsiveness. The first stage is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. Audible grunting, nasal flaring, and chest retractions may be present; however, these behaviors usually resolve within 1 hour of life.

Which medications are used to manage PPH? (Select all that apply.) a.Oxytocin b.Methergine c.Terbutaline d.Hemabate e.Magnesium sulfate

ANS: A, B, D Oxytocin, Methergine, and Hemabate are medications used to manage PPH. Terbutaline and magnesium sulfate are tocolytic medications that are used to relax the uterus, which would cause or worsen PPH.

Lacerations of the cervix, vagina, or perineum are also causes of PPH. Which factors influence the causes and incidence of obstetric lacerations of the lower genital tract? (Select all that apply.) a.Operative and precipitate births b.Adherent retained placenta c.Abnormal presentation of the fetus d.Congenital abnormalities of the maternal soft tissue e.Previous scarring from infection

ANS: A, C, D, E Abnormal adherence of the placenta occurs for unknown reasons. Attempts to remove the placenta in the usual manner can be unsuccessful, and lacerations or a perforation of the uterine wall may result. However, attempts to remove the placenta do not influence lower genital tract lacerations. Lacerations of the perineum are the most common of all lower genital tract injuries and often occur with both precipitate and operative births and are classified as first-, second-, third-, and fourth-degree lacerations. An abnormal presentation or position of the fetus, the relative size of the presenting part, and the birth canal may contribute to lacerations of the lower genital tract. Congenital abnormalities, previous scarring from infection or injury, and a contracted pelvis may also influence injury to the lower genital tract, followed by hemorrhage.

What is the rationale for evaluating the plantar crease within a few hours of birth? a.Newborn has to be footprinted. b.As the skin dries, the creases will become more prominent. c.Heel sticks may be required. d.Creases will be less prominent after 24 hours.

ANS: B As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. Footprinting nor heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.

Which statement best describes the transition period between intrauterine and extrauterine existence for the newborn? a.Consists of four phases, two reactive and two of decreased responses b.Lasts from birth to day 28 of life c.Applies to full-term births only d.Varies by socioeconomic status and the mother's age

ANS: B Changes begin immediately after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. This transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition period, regardless of age or type of birth. Although stress can cause variations in the phases, the mother's age and wealth do not disturb the pattern.

The process during which bilirubin is changed from a fat-soluble product to a water-soluble product is known as what? a.Enterohepatic circuit b.Conjugation of bilirubin c.Unconjugated bilirubin d.Albumin binding

ANS: B Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product and is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and is then recycled into the intestine. Unconjugated bilirubin is a fat-soluble product. Albumin binding is the process during which something attaches to a protein molecule.

The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive? a.To reduce the risk for jaundice b.To reduce the risk of intraventricular hemorrhage c.To decrease total blood volume d.To improve the ability to fight infection

ANS: B Delayed cord clamping provides the greatest benefits to the preterm infant. These benefits include a significant reduction in intraventricular hemorrhage, a reduced need for a blood transfusion, and improved blood cell volume. The risk of jaundice can increase, requiring phototherapy. Although no difference in the newborn's infection fighting ability occurs, iron status is improved, which can provide benefits for 6 months.

Parents have asked the nurse about organ donation after that infant's death. Which information regarding organ donation is important for the nurse to understand? a.Federal law requires the medical staff to ask the parents about organ donation and then to contact their state's organ procurement organization (OPO) to handle the procedure if the parents agree. b.Organ donation can aid grieving by giving the family an opportunity to see something positive about the experience. c.Most common donation is the infant's kidneys. d.Corneas can be donated if the infant was either stillborn or alive as long as the pregnancy went full term.

ANS: B Evidence indicates that organ donation can promote healing among the surviving family members. The federal Gift of Life Act made state OPOs responsible for deciding whether to request a donation and for making that request. The most common donation is the cornea. For cornea donation, the infant must have been born alive at 36 weeks of gestation or later.

Which client is at greatest risk for early PPH? a.Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress b.Woman with severe preeclampsia on magnesium sulfate whose labor is being induced c.Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor d.Primigravida in spontaneous labor with preterm twins

ANS: B Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. A primiparous woman being prepared for an emergency cesarean birth for fetal distress, a multiparous woman with an 8-hour labor, and a primigravida in spontaneous labor with preterm twins do not indicate risk factors or causes of early PPH

Which finding would indicate to the nurse that the grieving parents have progressed to the reorganization phase of grieving? a.The parents say that they "feel no pain." b.The parents are discussing sex and a future pregnancy, even if they have not yet sorted out their feelings. c.The parents have abandoned those moments of "bittersweet grief." d.The parents' questions have progressed from "Why?" to "Why us?"

ANS: B Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly beyond the first year when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, such as anniversary dates. Most couples never abandon these reminders. Recovery is ongoing. Typically, a couple's search for meaning progresses from "Why?" in the acute phase to "Why me?" in the intense phase to "What does this loss mean to my life?" in the reorganizational phase.

The condition during which infants are at an increased risk for subgaleal hemorrhage is called what? a.Infection b.Jaundice c.Caput succedaneum d.Erythema toxicum neonatorum

ANS: B Subgaleal hemorrhage is bleeding into the subgaleal compartment and is the result of the transition from a forceps or vacuum application. Because of the breakdown of the red blood cells within a hematoma, infants are at greater risk for jaundice. Subgaleal hemorrhage does not increase the risk for infections. Caput succedaneum is an edematous area on the head caused by pressure against the cervix. Erythema toxicum neonatorum is a benign rash of unknown cause that consists of blotchy red areas.

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. What information provided by the nurse would be most useful to these new parents? a."Infants can see very little until approximately 3 months of age." b."Infants can track their parents' eyes and can distinguish patterns; they prefer complex patterns." c."The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d."It's important to shield the newborn's eyes. Overhead lights help them see better."

ANS: B Telling the parents that infants can track their parents' eyes and can distinguish patterns is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. They prefer low illumination and withdraw from bright lights.

A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse? a."He will only wake up to be fed, and you should not bother him between feedings." b."The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing." c."He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon." d."He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night."

ANS: B Telling the woman that the newborn sleeps approximately 17 hours a day with periods of wakefulness that gradually increase is both accurate and the most appropriate response by the nurse. Periods of wakefulness are dictated by hunger, but the need for socializing also appears. Telling the woman that her infant is stubborn and should be kept awake during the daytime is an inappropriate nursing response.

Which information about variations in the infant's blood counts is important for the nurse to explain to the new parents? a.A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord. b.An early high white blood cell (WBC) count is normal at birth and should rapidly decrease. c.Platelet counts are higher in the newborn than in adults for the first few months. d.Even a modest vitamin K deficiency means a problem with the blood's ability to properly clot.

ANS: B The WBC count is normally high on the first day of birth and then rapidly declines. Delayed cord clamping results in an increase in hemoglobin and the red blood cell count. The platelet count is essentially the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the deficiency of vitamin K is significant.

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness? a.Transition period b.First period of reactivity c.Organizational stage d.Second period of reactivity

ANS: B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. An organizational stage is not a valid stage. The second period of reactivity occurs approximately between 4 and 8 hours after birth, after a period of sleep.

A client is diagnosed with having a stillborn infant. At first, she appears stunned by the news, cries a little, and then asks the nurse to call her mother. What is the proper term for the phase of bereavement that this client is experiencing? a.Anticipatory grief b.Acute distress c.Intense grief d.Reorganization

ANS: B The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, a lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

What is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony? a.Establishing venous access b.Performing fundal massage c.Preparing the woman for surgical intervention d.Catheterizing the bladder

ANS: B The initial management of excessive postpartum bleeding is a firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, fundal massage is the initial intervention. The woman may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention is to assess the uterus. After uterine massage, the nurse may want to catheterize the client to eliminate any bladder distention that may be preventing the uterus from properly contracting.

A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, "He looks just fine to me. I can't understand what all this is about." What is the most appropriate response or reaction by the nurse at this time? a."Didn't the physician tell you about your son's problems?" b."This must be a difficult time for you. Tell me how you're doing." c.Quietly stand beside the infant's father. d."You'll have to face up to the fact that he is going to die sooner or later."

ANS: B The phase of intense grief can be very difficult, especially for fathers. Parents should be encouraged to share their feelings during the initial steps in the grieving process. This father is in a phase of acute distress and is reaching out to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through a sharing and verbalization of their feelings of grief. Telling the father that his son is going to die sooner or later is dispassionate and an inappropriate statement on the part of the nurse.

During a follow-up home visit, the nurse plans to evaluate whether parents have progressed to the second stage of grieving (phase of intense grief). Which behavior would the nurse not anticipate finding? a.Guilt, particularly in the mother b.Numbness or lack of response c.Bitterness or irritability d.Fear and anxiety, especially about getting pregnant again

ANS: B The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, which indicates that the parents are still in denial or shock.

What would a steady trickle of bright red blood from the vagina in the presence of a firm fundus suggest to the nurse? a.Uterine atony b.Lacerations of the genital tract c.Perineal hematoma d.Infection of the uterus

ANS: B Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm in the presence of uterine atony. A hematoma would develop internally. Swelling and discoloration would be noticeable; however, bright bleeding would not be. With an infection of the uterus, an odor to the lochia and systemic symptoms such as fever and malaise would be present.

Which cardiovascular changes cause the foramen ovale to close at birth? a.Increased pressure in the right atrium b.Increased pressure in the left atrium c.Decreased blood flow to the left ventricle d.Changes in the hepatic blood flow

ANS: B With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth and is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes but is not the reason for the closure of the foramen ovale.

What are the various modes of heat loss in the newborn? (Select all that apply.) a.Perspiration b.Convection c.Radiation d.Conduction e.Urination

ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.

The nurse should be cognizant of which important information regarding the gastrointestinal (GI) system of the newborn? a.The newborn's cheeks are full because of normal fluid retention. b.The nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. c.Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. d.Bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.

ANS: C Avoiding overfeeding can also reduce regurgitation. The newborn's cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.

Which is the initial treatment for the client with vWD who experiences a PPH? a.Cryoprecipitate b.Factor VIII and von Willebrand factor (vWf) c.Desmopressin d.Hemabate

ANS: C Desmopressin is the primary treatment of choice for vWD and can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer. Treatment with plasma products such as factor VIII and vWf is an acceptable option for this client. Because of the repeated exposure to donor blood products and possible viruses, this modality is not the initial treatment of choice. Although the administration of the prostaglandin, Hemabate, is known to promote contraction of the uterus during PPH, it is not effective for the client who has a bleeding disorder.

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action is the highest priority for the nurse to take at this time? a.Immediately notify the physician. b.Move the newborn to an isolation nursery. c.Document the finding as erythema toxicum neonatorum. d.Take the newborn's temperature, and obtain a culture of one of the vesicles.

ANS: C Erythema toxicum neonatorum (or erythema neonatorum) is a newborn rash that resembles flea bites. Notification of the physician, isolation of the newborn, or additional interventions are not necessary when erythema toxicum neonatorum is present.

How would the nurse differentiate a meconium stool from a transitional stool in the healthy newborn? a.Observed at age 3 days b.Is residue of a milk curd c.Passes in the first 12 hours of life d.Is lighter in color and looser in consistency

ANS: C Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, then obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.

Which options for saying "good-bye" would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a.The nurse should not discuss any options at this time; plenty of time will be available after the baby is born. b."Would you like a picture taken of your baby after birth?" c."When your baby is born, would you like to see and hold her?" d."What funeral home do you want notified after the baby is born?"

ANS: C Mothers and fathers may find it helpful to see their infant after delivery. The parents' wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. The initial intervention should be directly related to the parents' wishes concerning seeing or holding their dead infant. Although information about funeral home notification may be relevant, this information is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination, the nurse notices warmth and redness over an enlarged, hardened area. Which condition should the nurse suspect, and how will it be confirmed? a.Disseminated intravascular coagulation (DIC); asking for laboratory tests b.von Willebrand disease (vWD); noting whether bleeding times have been extended c.Thrombophlebitis; using real-time and color Doppler ultrasound d.Idiopathic or immune thrombocytopenic purpura (ITP); drawing blood for laboratory analysis

ANS: C Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely thrombophlebitis. A Doppler ultrasound examination is a common noninvasive way to confirm the diagnosis. A diagnosis of DIC is made according to clinical findings and laboratory markers. With DIC, a physical examination will reveal symptoms that may include unusual bleeding, petechiae around a blood pressure cuff on the woman's arm, and/or excessive bleeding from the site of a slight trauma such as a venipuncture site. Symptoms of vWD, a type of hemophilia, include recurrent bleeding episodes, prolonged bleeding time, and factor VIII deficiency. A risk for PPH exists with vWD but does not exhibit a warm or reddened area in an extremity. ITP is an autoimmune disorder in which the life span of antiplatelet antibodies is decreased. Increased bleeding time is a diagnostic finding, and the risk of postpartum uterine bleeding is increased.

Which statement most accurately describes complicated grief? a.Occurs when, in multiple births, one child dies and the other or others live b.Is a state during which the parents are ambivalent, as with an abortion c.Is an extremely intense grief reaction that persists for a long time d.Is felt by the family of adolescent mothers who lose their babies

ANS: C Parents showing signs of complicated grief should be referred for counseling. Multiple births, in which not all of the babies survive, create a complicated parenting situation but not complicated bereavement. Abortion can generate complicated emotional responses, but these responses do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but these issues are not complicated bereavement.

What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? a.Mongolian spots on the back b.Telangiectatic nevi on the nose or nape of the neck c.Petechiae scattered over the infant's body d.Erythema toxicum neonatorum anywhere on the body

ANS: C Petechiae (bruises) scattered over the infant's body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but gradually fade over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum neonatorum is an appalling-looking rash; however, it has no clinical significance and requires no treatment.

A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact 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 the infant blood types. c.Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life. d.Physiologic jaundice is also known as breast milk jaundice.

ANS: C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dl or higher when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice, not physiologic jaundice, occurs during the first 24 hours of life and is caused by blood incompatibilities that result in excessive destruction of erythrocytes; this condition must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful? a.Using the words lost or gone rather than dead or died b.Making sure the family understands that naming the baby is important c.Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby d.Setting a firm time for ending the visit with the baby so that the parents know when to let go

ANS: C Presenting the baby as nicely as possible stimulates the parents' senses and provides pleasant memories of their baby. Baby lotion or powder can be applied, and the baby should be wrapped in a soft blanket, clothed, and have a cap placed on his or her head. Nurses must use the words dead and died to assist the bereaved in accepting the reality. Although naming the baby can be helpful, creating the sense that the parents have to name the baby is not important. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different times with their baby to say "good-bye." Nurses need to be careful not to rush the process.

The most effective and least expensive treatment of puerperal infection is prevention. What is the most important strategy for the nurse to adopt? a.Large doses of vitamin C during pregnancy b.Prophylactic antibiotics c.Strict aseptic technique, including hand washing, by all health care personnel d.Limited protein and fat intake

ANS: C Strict adherence by all health care personnel to aseptic techniques during childbirth and the postpartum period is extremely important and the least expensive measure to prevent infection. Good nutrition to control anemia is a preventive measure. Increased iron intake assists in preventing anemia. Antibiotics may be administered to manage infections; they are not a cost-effective measure to prevent postpartum infection. Limiting protein and fat intake does not help prevent anemia or prevent infection.

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what? a.Polydactyly b.Clubfoot c.Hip dysplasia d.Webbing

ANS: C The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.

The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)? a.80 to 100 b.100 to 120 c.120 to 160 d.150 to 180

ANS: C The average infant heart rate while awake is 120 to 160 beats per minute. The newborn's heart rate may be approximately 85 to 100 beats per minute while sleeping and typically a little higher than 100 to 120 beats per minute when alert but quiet. A heart rate of 150 to 180 beats per minute is typical when the infant cries.

The nurse is cognizant of which information related to the administration of vitamin K? a.Vitamin K is important in the production of red blood cells. b.Vitamin K is necessary in the production of platelets. c.Vitamin K is not initially synthesized because of a sterile bowel at birth. d.Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice.

ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood-clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other blood-clotting factors.

A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation presents a problem for the newborn. What is the rationale for this difficulty? a.The renal function of a newborn is not fully developed, and heat is lost in the urine. b.The small body surface area of a newborn favors more rapid heat loss than does an adult's body surface area. c.Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation. d.Their normal flexed posture favors heat loss through perspiration.

ANS: C The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the surface of the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss does not occur through urination. Newborns have a higher body surface-to-weight ratio than adults. The flexed position of the newborn helps guard against heat loss, because it diminishes the amount of body surface exposed to the environment.

Which information related to the newborn's developing cardiovascular system should the nurse fully comprehend? a.The heart rate of a crying infant may rise to 120 beats per minute. b.Heart murmurs heard after the first few hours are a cause for concern. c.The point of maximal impulse (PMI) is often visible on the chest wall. d.Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C The newborn's thin chest wall often allows the PMI to be observed. The normal heart rate for infants who are not sleeping is 120 to 160 beats per minute. However, a crying infant could temporarily have a heart rate of 180 beats per minute. Heart murmurs during the first few days of life have no pathologic significance; however, an irregular heart rate beyond the first few hours should be further evaluated. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. What is the nurse's role at this time? a.To take over as much as possible to relieve the pressure b.To encourage the grandparents to take over c.To ensure that the parents, themselves, approve the final decisions d.To leave them alone to work things out

ANS: C The nurse is always the client's advocate. Nurses can offer support and guidance and yet leave room for the same from grandparents. In the end, however, nurses should let the parents make the final decisions. For the nurse to be able to present options regarding burial and autopsy, among other issues, in a sensitive and respectful manner is essential. The nurse should assist the parents in any way possible; however, taking over all arrangements is not the nurse's role. Grandparents are often called on to help make the difficult decisions regarding funeral arrangements or the disposition of the body because they have more life experiences with taking care of these painful, yet required arrangements. Some well-meaning relatives may try to take over all decision-making responsibilities. The nurse must remember that the parents, themselves, should approve all of the final decisions. During this time of acute distress, the nurse should be present to provide quiet support, answer questions, obtain information, and act as a client advocate.

An African-American woman noticed some bruises on her newborn daughter's buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client? a.Lanugo b.Vascular nevus c.Nevus flammeus d.Mongolian spot

ANS: D A Mongolian spot is a bluish-black area of pigmentation that may appear over any part of the exterior surface of the infant's body and is more commonly noted on the back and buttocks and most frequently observed on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair observed on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port wine stain, is most frequently found on the face.

A family is visiting two surviving triplets. The third triplet died 2 days ago. What action indicates that the family has begun to grieve for the dead infant? a.Refers to the two live infants as twins b.Asks about the dead triplet's current status c.Brings in play clothes for all three infants d.Refers to the dead infant in the past tense

ANS: D Accepting that the infant is dead (in the past tense of the word) demonstrates an acceptance of the reality and that the family has begun to grieve. Parents of multiples are challenged with the task of parenting and grieving at the same time. Referring to the two live infants as twins does not acknowledge an acceptance of the existence of their third child. Bringing in play clothes for all three infants indicates that the parents are still in denial regarding the death of the third triplet. The death of the third infant has imposed a confusing and ambivalent induction into parenthood for this couple. If the two live infants are referred to as twins and/or if play clothes for all three infants are still considered, then the family is clearly still in denial regarding the death of one of the triplets.

Which statement is the most appropriate for the nurse to make when caring for bereaved parents? a."This happened for the best." b."You have an angel in heaven." c."I know how you feel." d."What can I do for you?"

ANS: D Acknowledging the loss and being open to listening is the best action that the nurse can do. No bereaved parent would find the statement "This has happened for the best" to be comforting in any way, and it may sound judgmental. Nurses must resist the impulse to speak about the afterlife to people in pain. They should also resist the temptation to give advice or to use clichés. Unless the nurse has lost a child, he or she does not understand how the parents feel.

If nonsurgical treatment for late PPH is ineffective, which surgical procedure would be appropriate to correct the cause of this condition? a.Hysterectomy b.Laparoscopy c.Laparotomy d.Dilation and curettage (D&C)

ANS: D D&C allows the examination of the uterine contents and the removal of any retained placental fragments or blood clots. Hysterectomy is the removal of the uterus and is not the appropriate treatment for late PPH. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity, but it, too, is not the appropriate treatment for this condition. A laparotomy is the surgical incision into the peritoneal cavity to explore it but is also not the appropriate treatment for late PPH.

Nurses need to understand the basic definitions and incidence data regarding PPH. Which statement regarding this condition is most accurate? a.PPH is easy to recognize early; after all, the woman is bleeding. b.Traditionally, it takes more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth to define the condition as PPH. c.If anything, nurses and physicians tend to overestimate the amount of blood loss. d.Traditionally, PPH has been classified as early PPH or late PPH with respect to birth.

ANS: D Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH. Unfortunately, PPH can occur with little warning and is often recognized only after the mother has profound symptoms. Traditionally, a 500-ml blood loss after a vaginal birth and a 1000-ml blood loss after a cesarean birth constitute PPH. Medical personnel tend to underestimate blood loss by as much as 50% in their subjective observations.

The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis? a.Absence of cyanosis in the buccal mucosa b.Cool, dry skin c.Calm mental status d.Urinary output of at least 30 ml/hr

ANS: D Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation during which the perfusion of body organs may become severely compromised, and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective. The presence of cool, pale, clammy skin is associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a.The nurse should immediately notify the pediatrician for this emergency situation. b.The neonate must have aspirated surfactant. c.If this baby was born vaginally, then a pneumothorax could be indicated. d.The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth.

ANS: D Moist lung sounds will resolve within a few hours. A surfactant acts to keep the expanded alveoli partially open between respirations for this common condition of newborns. In a vaginal birth, absorption of the remaining lung fluid is accelerated by the process of labor and delivery. The remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. Moist lung sounds are particularly common in infants delivered by cesarean section. The surfactant is produced by the lungs; therefore, aspiration is not a concern.

Which classification of placental separation is not recognized as an abnormal adherence pattern? a.Placenta accreta b.Placenta increta c.Placenta percreta d.Placenta abruptio

ANS: D Placenta abruptio is premature separation of the placenta as opposed to partial or complete adherence. This classification occurs between the 20th week of gestation and delivery in the area of the decidua basalis. Symptoms include localized pain and bleeding. Placenta accreta is a recognized degree of attachment. With placenta accreta, the trophoblast slightly penetrates into the myometrium. Placenta increta is a recognized degree of attachment that results in deep penetration of the myometrium. Placenta percreta is the most severe degree of placental penetration that results in deep penetration of the myometrium. Bleeding with complete placental attachment occurs only when separation of the placenta is attempted after delivery. Treatment includes blood component therapy and, in extreme cases, hysterectomy may be necessary.

What is one of the initial signs and symptoms of puerperal infection in the postpartum client? a.Fatigue continuing for longer than 1 week b.Pain with voiding c.Profuse vaginal lochia with ambulation d.Temperature of 38° C (100.4° F) or higher on 2 successive days

ANS: D Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth. Fatigue is a late finding associated with infection. Pain with voiding may indicate a urinary tract infection (UTI), but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.

Parents are often asked if they would like to have an autopsy performed on their infant. Nurses who are assisting parents with this decision should be aware of which information? a.Autopsies are usually covered by insurance. b.Autopsies must be performed within a few hours after the infant's death. c.In the current litigious society, more autopsies are performed than in the past. d.Some religions prohibit autopsy.

ANS: D Some religions prohibit autopsies or limit the choice to the times when it may help prevent further loss. The cost of the autopsy must be considered; it is not covered by insurance and can be very expensive. There is no rush to perform an autopsy unless evidence of a contagious disease or maternal infection is present at the time of death. The rate of autopsies is declining, in part because of a fear by medical facilities that errors by the staff might be revealed, resulting in litigation.

A nurse caring for a family during a loss might notice that a family member is experiencing survivor guilt. Which family member is most likely to exhibit this guilt? a.Siblings b.Mother c.Father d.Grandparents

ANS: D Survivor guilt is sometimes felt by grandparents because they feel that the death is out of order; they are still alive, while their grandchild has died. They may express anger that they are alive and their grandchild is not. The siblings of the expired infant may also experience a profound loss. A young child will respond to the reactions of the parents and may act out. Older children have a more complete understanding of the loss. School-age children are likely to be frightened, whereas teenagers are at a loss on how to react. The mother of the infant is experiencing intense grief at this time. She may be dealing with questions such as, "Why me?" or "Why my baby?" and is unlikely to be experiencing survival guilt. Realizing that fathers can be experiencing deep pain beneath their calm and quiet appearance and may need help acknowledging these feelings is important. This need, however, is not the same as survivor guilt.

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive _____ reflex. a.tonic neck b.glabellar (Myerson) c.Babinski d.Moro

ANS: D The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar (Myerson) reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

What is the most critical physiologic change required of the newborn after birth? a.Closure of fetal shunts in the circulatory system b.Full function of the immune defense system c.Maintenance of a stable temperature d.Initiation and maintenance of respirations

ANS: D The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes significantly after birth as a result of fetal respirations, which reduce pulmonary vascular resistance to the pulmonary blood flow and initiate a chain of cardiac changes that support the cardiovascular system. After the establishment of respirations, heat regulation is critical to newborn survival. The infant relies on passive immunity received from the mother for the first 3 months of life.

Which infant response to cool environmental conditions is either not effective or not available to them? a.Constriction of peripheral blood vessels b.Metabolism of brown fat c.Increased respiratory rates d.Unflexing from the normal position

ANS: D The newborn's flexed position guards against heat loss, because it reduces the amount of body surface exposed to the environment. The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" What is the nurse's most appropriate response? a."That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them." b."That's not likely. Paint is associated with elevated pediatric lead levels." c.Silence. d."I can understand your need to find an answer to what caused this. What else are you thinking about?"

ANS: D The statement "I can understand your need to find an answer to what caused this. What else are you thinking about?" is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grieving. Silence would probably increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and then listening with care. The nurse should encourage the mother to express her thoughts.

The brain is vulnerable to nutritional deficiencies and trauma in early infancy. What is the rationale for this physiologic adaptation in the newborn? a.Incompletely developed neuromuscular system b.Primitive reflex system c.Presence of various sleep-wake states d.Cerebellum growth spurt

ANS: D The vulnerability of the brain is likely due to the cerebellum growth spurt. By the end of the first year, the cerebellum ends its growth spurt that began at approximately 30 weeks of gestation. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant to the cerebellum growth spurt. The various sleep-wake states are not relevant to the cerebellum growth spurt.

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which of the following is a facilitating behavior? A.The parents have difficulty naming the infant. B.The parents hover around the infant, directing attention to and pointing at the infant. C.The parents make no effort to interpret the actions or needs of the infant. D.The parents do not move from fingertip touch to palmar contact and holding.

B. Hovering over the infant, as well as obviously paying attention to the baby, is a facilitating behavior. The other choices are inhibiting behaviors.

Which statement is inaccurate with regard to a nurse working with parents who have a sensory impairment? A.One of the major difficulties visually impaired parents experience is the skepticism of health care professionals. B.Visually impaired mothers cannot overcome the infant's need for eye-to-eye contact. C.The best approach for the nurse is to assess the parents' capabilities rather than focusing on their disabilities. D.Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information.

B. Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. The skepticism, open or hidden, of health care professionals throws up an additional and unneeded hurdle for the parents. After the parents' capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help a pick up a child's cry. Sign language is acquired readily by young children.

Which statement accurately reflects the La cuarentena ritual for a Hispanic patient? A.No restrictions are placed on the mother during this ritual period. B.This ritual occurs over a period of 40 days. C.Spicy foods are encouraged as part of the maternal diet. D.The ritual is limited to preparing the woman to become a good mother.

B. The La cuarentena ritual occurs during a period of 40 days. The La cuarentena ritual period involves certain dietary and behavioral restrictions—spicy foods are restricted—and involves an intergenerational family approach toward integrating the family unit.

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? A. Talks and coos to her son B.Seldom makes eye contact with her son C. Cuddles her son close to her D. Tells visitors how well her son is feeding

B. The woman should be encouraged to hold her infant in the en face position and make eye contact with him. Talking and cooing to her son, cuddling, and sharing her son's success at feeding are all normal infant-parent interactions or actions.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: A. Place her on a bedpan to empty her bladder B. Massage her fundus C. Call the physician D. Administer methylergonovine (Methergine), 0.2 mg IM, which has been ordered prn

B. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm. The physician can be called or methylergonovine administered after the fundus massage, especially if the fundus does not become or remain firm with massage. There is no indication of a distended bladder, so having the woman urinate will not alleviate the problem.

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious likely consequence of bladder distention is: A. Urinary tract infection. B. Excessive uterine bleeding. C. A ruptured bladder. D. Bladder wall atony.

B. Excessive uterine bleeding. Correct Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

Which description of postpartum restoration or healing times is accurate? A. The cervix shortens, becomes firm, and returns to form within a month postpartum. B. Rugae reappear within 3 to 4 weeks. C. Most episiotomies heal within a week. D. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

B. Rugae reappear within 3 to 4 weeks. Correct Rugae are never again as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function resumes. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

The nurse is observing a postpartum patient who has been bleeding excessively during the first hour, saturating multiple pads. Which interventions would the nurse anticipate that the physician would order? (Select all that apply.) A. Document findings in the health care record B. Decrease flow rate for intravenous fluid administration C. Administer oxygen via nonrebreather mask @ 10 L/minute D. Insert a secondary intravenous line access E. Type & screen for 2 units of blood

C, D Administration of oxygen @ 10L/minute via nonrebreather mask would be an anticipated order, as would insertion of a secondary line access for administration of fluids, blood, and/or medications. Although documentation of findings in a health care record is required, this is part of the nursing role and does not require an order by the physician. With regard to the presence of hypovolemic shock, intravenous fluids would be increased and maintained. The flow rate would not typically be decreased unless there was another comorbidity leading to potential fluid overload. Type & Screen would not be an anticipated order because no blood would be held for use; rather a Type & Cross order would be anticipate

While making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review the events and her behavior during the process of labor and birth. B.Exhibit a reduced attention span, limiting readiness to learn. C.Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. D.Have reestablished her role as a spouse or partner.

C. One week after birth the woman should exhibit behaviors characteristic of the dependent-independent or taking-hold stage. She still has needs for nurturing and acceptance by others. Wanting to discuss the events of her labor and delivery are characteristics of the taking-in stage, as are a limited readiness to learn and reduced attention span; this stage lasts from the first 24 hours until 2 days after delivery. Having reestablished her role as a spouse reflects the letting-go stage, which indicates that psychosocial recovery is complete.

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about a half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis? A. PPD symptoms are consistently severe. B.This syndrome affects only new mothers. C.PPD can easily go undetected. D.Only mental health professionals should teach new parents about this condition.

C. PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having good days and bad days. Screening should be done for mothers and fathers, because PPD may also occur in new fathers. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur.

Which test result would provide evidence of fetal blood in maternal circulation? A. Positive Fern test result B. Positive Coombs test result C. Positive Kleihauer-Betke test result D. Negative Coombs test result

C. A Kleihauer-Betke test determines the presence of fetal blood in maternal circulation. A positive fern test result would indicate the presence of amniotic fluid, noting that membranes had ruptured. A positive Coombs test result would indicate that the mother has Rh antibodies, and a negative result would indicate no presence of Rh antibodies.

With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: A. Kidney function returns to normal a few days after birth. B. Diastasis recti abdominis is a common condition that alters the voiding reflex. C. Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. D. With adequate emptying of the bladder, bladder tone is usually restored 2 to 3 weeks after childbirth.

C. Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. Correct Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth.

With regard to afterbirth pains, nurses should be aware that these pains are: A. Caused by mild, continual contractions for the duration of the postpartum period. B. More common in first-time mothers. C. More noticeable in births in which the uterus was overdistended. D. Alleviated somewhat when the mother breastfeeds.

C. More noticeable in births in which the uterus was overdistended. Correct A large baby or multiple babies overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

Nurses are getting ready for bedside reporting at change of shift. A benefit of this type of change of shift report is that: A. Information is transparent so that the nurses and patients are aware of all pertinent data and delivery of care aspects. B. Patients can ask questions of the nurses during change of shift report so that they can better direct the delivery of their health care. C. Nurses are able to visualize their patient's directly at the time of report leading to better patient satisfaction. D. There is no need for additional information to be exchanged as the patient is right there to answer questions and voice concerns.

C. Using a bedside report technique helps the nurse directly visualize the patient in question so as to improve his/her understanding of each patient's clinical situation. The transparency of information is not a benefit of bedside reporting. A bedside report is a change-of-shift report between nurses involved in the delivery of health care to a patient and/or group of patients; it is not mediated by patient questioning. Also, it is not all inclusive because patient care continues and is evolving over the course of the patient's hospitalization. Thus, additional information will be needed.

Excessive blood loss after childbirth can have several causes; however, the most common is: A. Vaginal or vulvar hematomas. B. Unrepaired lacerations of the vagina or cervix. C. Failure of the uterine muscle to contract firmly. D. Retained placental fragments.

C.Although vaginal or vulvar hematomas, unrepaired lacerations, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention.

Health care providers demonstrate a variety of reactions to lesbian couples, including failure to acknowledge the "other mother's" role in pregnancy, birth, and parenting. Integration of the nonchildbearing partner into care includes offering the same opportunities afforded male partners of heterosexual women. Which opportunity could not be provided to male partners? A.Labor support B.Cutting the cord C.Rooming-in during hospitalization D.Breastfeeding the infant

D. An option not available to male partners is to actually breastfeed the infant. The nonchildbearing female partner can stimulate milk production through induced lactation using medications and regular pumping. A supplemental feeding device containing expressed breast milk or formula can be used to provide additional milk to the breastfeeding infant. Labor support is a very appropriate role for the "other mother" or "co-parent." Pregnancy for lesbian couples is an intentional event, and generally both mothers will want to be very involved. As with heterosexual couples, if institutional policy allows, the nonbiologic mother should be allowed to cut the umbilical cord after delivery. Like any heterosexual parents, lesbian couples face challenges in adjusting to life with a new baby. Encouraging rooming-in assists with this transition.

Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse suspects: A. Bladder distention B. Uterine atony C. Constipation D. Hematoma formation

D. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation. Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time.

Postbirth uterine/vaginal discharge, called lochia: A. Is similar to a light menstrual period for the first 6 to 12 hours. B. Is usually greater after cesarean births. C. Will usually decrease with ambulation and breastfeeding. D. Should smell like normal menstrual flow unless an infection is present.

D. Should smell like normal menstrual flow unless an infection is present. Correct An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia is usually seen after cesarean births. It usually increases with ambulation and breastfeeding.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: A. Begin an IV infusion of Ringer's lactate solution. B. Assess the woman's vital signs. C. Call the woman's primary health care provider. D. Massage the woman's fundus.

D. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum. B. Washes from symphysis pubis back to the episiotomy. C. Changes her perineal pad every 2 to 3 hours. D. Uses the peribottle to rinse upward into her vagina.

D. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix. Using soap and warm water to wash the vulva and perineum is an appropriate measure. Washing from the symphysis pubis back to the episiotomy is an appropriate infection control measure. The client should be instructed to change her perineal pad every

Which finding would be a source of concern if noted during the assessment of a woman at 12 hours postpartum? A. Postural hypotension B. Temperature of 38° C C. Bradycardia—pulse rate of 55 beats/min D. Pain in left calf with dorsiflexion of left foot

D. These findings indicate presence of Homans sign, are suggestive of thrombophlebitis, and should be investigated. Postural hypotension is an expected finding related to circulatory changes after birth. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. A temperature of 38° C in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake.

What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? A. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." B. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." t C. "I will not have a menstrual cycle for 6 months after childbirth." D. "My first menstrual cycle will be heavier than normal and then will be light for several months after."

My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." Correct This is an accurate statement and indicates her understanding of her expected menstrual activity. The woman can expect her first menstrual cycle, which occurs by 3 months after childbirth, to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles