nclex-maternal-newborn
Accompanied by her husband, a client seeks admission to the labor and delivery area . She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first?
"What is your expected due date?" RATIONALES: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons.
After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at -1 station. Based on these findings, the nurse-midwife knows that the fetal presenting part is:
. 1 cm above the ischial spines. RATIONALES: Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as -1, -2, or -3. A presenting part below the ischial spines, as +1, +2, or +3.
A client who is 29 weeks pregnant comes to the labor and delivery unit. She states that she's having contractions every 8 minutes. The client is also 3 cm dilated. Which medications can the nurse expect to administer?
1. Betamethasone 2. Terbutaline (Brethine) 3. I.V. fluids RATIONALES: The client is at risk for preterm delivery. The nurse can expect that terbutaline, a beta-2 agonist that relaxes smooth muscle, will be administered to halt contractions. The nurse can also expect that betamethasone, a corticosteroid, will be administered to decrease the risk of respiratory distress in the infant if preterm delivery occurs. I.V. fluids will be used to expand the intravascular volume and decrease contractions, if dehydration is the cause. Folic acid is a mineral recommended throughout pregnancy (especially in the first trimester) to decrease the risk of neural tube defects. It isn't used to address preterm delivery. Rho (D) immune globulin is administered to Rh-negative clients who have been or are suspected of having been exposed to Rh-positive fetal blood. Meperidine is an opioid used during labor and delivery to manage pain.
The nurse is doing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero?
1.The neonate's toes don't curl downward when soles of feet are stroked 2The neonate doesn't respond when the nurse claps her hands above him. 3.The neonate displays weak, ineffective sucking RATIONALES: If the neonate's toes don't curl downward when the soles of his feet are stroked and he doesn't respond to a loud sound, it may be evidence that neurologic damage from asphyxia has occurred. A normal neurologic response would be the toes curling downward with stroking and extending arms and legs with a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate should grasp a person's finger when it's placed in the palm of his hand, do stepping movements when held upright with the sole of foot touching a surface, and turn toward the nurse's finger when she touches his cheek.
The nurse demonstrates infant bathing to a primiparous client. Which statement by the client indicates a lack of understanding?
2. "I have all kinds of pretty, scented soaps and lotions to bathe the baby with. RATIONALES: Scented and medicated soaps and lotions aren't recommended for infants because they may alter the skin pH, making the skin less able to fight infection. Bathing the infant in a warm room, sponge-bathing the infant until the cord area heals, and washing the eyes and face first are appropriate activities and indicate an understanding of teaching regarding infant bathing
Which of the following describes a preterm neonate
A neonate born at less than 37 weeks' gestation regardless of weight RATIONALES: A preterm neonate is a neonate born at less than 37 weeks' gestation regardless of what the neonate weighs. Neonates weighing less than 2,500 g are described as low-birth-weight neonates. A neonate who's small for gestational age weighs below the 10th percentile (or two standard deviations below the mean) as a result of intrauterine growth retardation.
A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which of the following would be the nurse's initial action
Assess for presence of a full bladder. RATIONALES: A full bladder will slow or stop cervical dilation and produce symptoms that could be misdiagnosed as arrest in labor. Other strategies, such as internal uterine monitoring, relaxation, and oxytocin augmentation, would be appropriate later, but assessing the bladder first is key.
For a client who's fully dilated, which of the following actions would be inappropriate during the second stage of labor?
Assessing for rupture of membranes RATIONALES: In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor. Positioning for effective pushing, preparing for delivery, and assessing vital signs every 15 minutes are appropriate actions at this time.
Which of the following is the primary reason for putting breast-feeding neonates to the breast immediately after delivery?
Breast-feeding neonates immediately after birth establishes a learned response RATIONALES: Immediately following birth, most neonates are quietly alert and are ready to nurse. Therefore, this is an ideal time to begin breast-feeding. Also, as one of the first postbirth experiences, the neonate is able to develop a learned response for feeding. The other answers are acceptable, but they don't consider the importance of developing responses as part of breast-feeding succes
When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following
Fetal hypoxia RATIONALES: These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort.
The neonate's respiratory function stabilizes about 24 hours after birth and is maintained by the effects of biochemical and environmental stimulation. What four physiologic conditions must be present in order for the neonate's respiratory functioning to proceed?
Functioning respiratory center, patent airway, intact nerves from RATIONALES: Respiratory functioning requires a patent airway, a functioning respiratory center, intact nerves from the brain to the chest muscles, and adequate calories to supply energy for the labor of breathing. With birth comes functional closure of the fetal shunts. However, anatomic closure doesn't occur for up to 4 weeks. Clinically insignificant functional murmurs or transient cyanosis may result. Maintaining the neonate's body temperature is essential for successful extrauterine adaptation but isn't directly responsible for respiratory stabilization. brain to the chest muscles, and adequate calories .
The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?
RATIONALES: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated.
Which of the following describes the term fetal position?
Relationship of the fetus's presenting part to the mother's pelvis RATIONALES: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis.
Which of the following correctly defines puerperium?
The 6 weeks following birth
For a client in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?
The membranes must rupture. RATIONALES: Internal EFM can be applied only after the client's membranes have ruptured, when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. Although the client may receive anesthesia, it isn't required before application of an internal EFM device.
A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which of the following would be least likely if the neonate developed hemolytic disease?
Weight loss greater than 10% RATIONALES: Although weight loss may be greater than 10%, the most important assessments must include those addressing the problem of a rising bilirubin. Neonates who develop severe jaundice as a result of Rh and ABO incompatibility will exhibit lethargy or irritability and poor feeding patterns. If bilirubin levels are high enough to cross the blood brain barrier (usually 20 mg and higher), the neonate is at serious risk for neurologic impairment due to permanent cell damage (kernicterus
The nurse is assessing a client on the 2nd postpartum day. Under normal circumstances, the tone and location of the client's fundus is:
firm and two fingerbreadths below the umbilicus RATIONALES: By the 2nd postpartum day, the fundus should be firm and two fingerbreadths below the umbilicus. The fundus should be at the level of the umbilicus on the day of delivery and falls below the umbilicus by approximately one fingerbreadth (1 cm) per day, until it has contracted into the pelvis by the 9th or 10th day. The fundus should be firm, not soft. A soft or boggy fundus indicates that the uterus isn't contracting properly. The fundus should be palpated in the midline of the abdomen; if the woman has a full bladder, however, the fundus may be deviated to the right or left.
A client who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse expects to find
irritability and poor sucking RATIONALES: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies.
A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for
uterine atony .RATIONALES: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.
A full-term neonate is diagnosed with hydrocephalus. Nursing assessment is most likely to reveal:
wide or bulging fontanels. RATIONALES: Hydrocephalus typically causes an enlarged head with wide or bulging fontanels, an excessive diameter (increased occipitofrontal diameter), a shiny scalp with prominent veins, separation of the suture lines, and downward-slanting eyes. Other findings in hydrocephalus include bradycardia, apneic episodes, vomiting, irritability, excessive crying, and reduced alertnes
