NSG312 Exam #4 Lippencott

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? shock disseminated intravascular coagulation (DIC) hemorrhage infection

A full bladder prevents the uterus from contracting completely, increasing the risk of hemorrhage. It doesn't directly increase the risk of shock, DIC, or infection.

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Labor was unusually long and required oxytocin augmentation. The nurse who's caring for the client should stay alert for uterine inversion. atony. involution. discomfort.

A large fetus, extended labor, stimulation with oxytocin, and traumatic birth commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow birth 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 childbirth.

While caring for a postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibits which symptom? pain in their calf dyspnea hypertension bradycardia

A major complication of deep vein thrombosis is pulmonary embolism. Signs and symptoms, which may occur suddenly and require immediate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub. Pain in the calf is common with a diagnosis of deep vein thrombosis. Hypotension, not hypertension, would suggest a possible pulmonary embolism. It also could suggest possible hemorrhage secondary to intravenous heparin therapy. Bradycardia for the first 7 days in the postpartum period is normal.

What manifestations would the nurse expect to find in a preterm neonate with cold stress? yellowish undercast to the skin color increased abdominal girth hyperactivity and twitching slowed respirations

A neonate with cold stress must produce heat through increased metabolism, causing oxygen use to increase and glycogen stores to be quickly depleted leading to hypoglycemia. Hyperactivity and twitching are signs of hypoglycemia. Yellowish undercast to the skin color suggests jaundice related to excessive bilirubin levels, not cold stress. Increased abdominal girth suggests abdominal distention, possibly indicating necrotizing enterocolitis. It is unrelated to cold stress or possible hypoglycemia. Increased, not slowed, respirations are associated with neonatal cold stress and hypoglycemia.

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which action in the infant's plan of care? urine toxicology screening notifying hospital security limiting contact with visitors contacting local law enforcement

A urine toxicology screening will be collected to document that the infant has been exposed to illegal drug use. This documentation will be the basis for legal action for the protection of this infant. If the infant tests positive for cocaine, the legal system will be activated to provide and ensure protective custody for this child. Hospital security would not become involved unless the birth parent is obtaining or using drugs on hospital premises. The parent and infant have the same privileges as any hospitalized clients unless the safety of the infant is jeopardized; thus, limiting contact with visitors would not be appropriate. Local law enforcement agencies would be contacted only if the parent initiates the use of drugs on hospital premises, and such contact would be made through the hospital security system.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? The vaccine prevents a future fetus from developing congenital anomalies. Pregnancy should be avoided for 4 weeks after the immunization. The client should avoid contact with children diagnosed with rubella. The injection will provide immunity against chickenpox.

After administration of the rubella vaccine, the client should be instructed to avoid pregnancy for at least 4 weeks to prevent the possibility of the vaccine's teratogenic effects on the fetus. The vaccine does not protect a future fetus from infection. Rather, it protects the client from developing the infection if exposed during pregnancy and subsequently causing harm to the fetus. The vaccine will provide immunity to rubella, also known as German measles. The injection immunizes the client against the 3-day or German measles, not chickenpox.

The nurse is interviewing a client with newly diagnosed syphilis. To prevent the spread of the disease, the nurse should focus the interview on which approach? motivating the client to undergo treatment obtaining a list of the client's sexual contacts increasing the client's knowledge of the disease reassuring the client that medical records are confidential

An important aspect of controlling the spread of sexually transmitted diseases (STDs) is obtaining a list of the sexual contacts of an infected client. These contacts, in turn, should be encouraged to obtain immediate care. Many people with STDs are reluctant to reveal their sexual contacts, which makes controlling STDs difficult. Increasing clients' knowledge of the disease and reassuring clients that their records are confidential can motivate them to seek treatment, which helps to control the spread of the disease, but it is not as critical as information about the client's sexual contacts.

Which measure would be most effective in helping the infant with a cleft lip and palate to retain oral feedings? Burp the infant at frequent intervals. Feed the infant small amounts at one time. Place the end of the nipple far to the back of the infant's tongue. Maintain the infant in a supine position while feeding.

An infant with a cleft lip and palate typically swallows large amounts of air while being fed and therefore should be burped frequently. The soft palate defect allows air to be drawn into the pharynx with each swallow of formula. The stomach becomes distended with air, and regurgitation, possibly with aspiration, is likely if the infant is not burped frequently. Feeding frequently, even in small amounts, would not prevent swallowing of large amounts of air. A nipple placed in the back of the mouth is likely to cause the infant to gag and aspirate. Holding the infant in a supine position during feedings can also lead to regurgitation and aspiration of formula. The infant should be fed in an upright position.

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing? drug withdrawal first period of reactivity a state of deep sleep respiratory distress

At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress in this scenario because the neonate's respiratory rate of 35 breaths/min is normal.

While the nurse is palpating the breasts of a client who is breastfeeding their 12-hour-old neonate, what is an expected finding? soft breasts that are not tender to touch slightly firm, filling breasts firm breasts beginning milk production firm breasts that are tender to touch

Because the client is 12 hours postpartum, the breasts should still be soft and not tender to touch. Breast milk production does not begin until the second or third postpartum day. Therefore, this client's breasts would not be firm with noticeable filling. When production begins, the breasts become larger, firm, and tender to touch.

A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client? activity intolerance sleep deprivation situational low self-esteem risk for infection

Birth trauma and prolonged ruptured membranes make the risk for infection the priority problem for this client. Infection can be a serious postpartum complication. Although the client may be fatigued, they should not be experiencing activity intolerance. Clients with heart disease may experience activity intolerance due to excessive cardiac workload. Although the client may be experiencing sleep deprivation, most clients are alert and awake after the birth of a neonate. Situational low self-esteem is not a priority. Clients who undergo a cesarean birth commonly feel a sense of failure because of not having a vaginal birth experience, but this is not the case for this client.

A multiparous client who is breastfeeding has severe cramps or afterpains 28 hours after cesarean birth. The nurse explains that these are caused by which factor? flatulence accumulation after a cesarean birth healing of the abdominal incision after cesarean birth adverse effects of the medications administered after birth release of oxytocin during the breastfeeding session

Breastfeeding stimulates oxytocin secretion, which causes the uterine muscles to contract. These contractions account for the discomfort associated with afterpains. Flatulence may occur after a cesarean birth. However, the client typically would have abdominal distention and a bloating feeling, not a "cramp-like" feeling. Stretching of the tissues or healing may cause slight tenderness or itching, not cramping feelings of discomfort. Medications such as mild analgesic agents or stool softeners, which are commonly administered after birth, typically do not cause cramping.

A newborn diagnosed with phenylketonuria (PKU) is placed on a low-phenylalanine formula. The parent asks the nurse how long their infant will need to have a dietary restriction. Which response would be most appropriate? "Your baby needs to stay on low-phenylalanine formula until they are taking solid foods well." "Once your child has stopped growing, they can come off the phenylalanine restricted diet." "Your child can switch to a regular diet when phenylalanine levels remain normal for 6 months." "Most likely your child will need to follow a low-phenylalanine diet for the rest of their life."

Clients with PKU have better cognitive outcomes and long-term health when they remain on a low-phenylalanine diet their entire life. Clients who follow the PKU diet will not get enough essential nutrients from food. They will have to drink a special formula for the rest of their lives, but older children and adults will drink a different formula than infants and toddlers. Older treatment plans permitted adolescents to come off the diet once they had stopped growing but advised female clients that they had to resume the diet before conception to lower risks to the fetus. It is now understood that rising phenylalanine levels in adolescents and young adults are associated with decreased mental well-being. The safe amount of dietary phenylalanine that clients with PKU can tolerate varies over time. Clients who stay on the diet will need regular phenylalanine monitoring for the rest of their lives.

Sick and preterm neonates who experience continuity of nursing care directly benefit from higher levels of professional satisfaction among nurses. higher levels of parent satisfaction with nursing care. nursing recognition of subtle changes in high-risk neonates' conditions. decreased hospital liability for professional malpractice.

Continuity of care allows the nurse to observe subtle changes in a neonate's condition. Although nurses and parents experience higher levels of satisfaction and professional liability may decline, these results aren't direct benefits to the neonate.

The health care provider orders docusate sodium 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication? Relief from episiotomy pain. Contraction of the uterus. Softening of the stool. Aid in sleeping.

Docusate sodium is a stool softener, used to assist in bowel elimination. The client is at risk for constipation because of decreased food and fluid intake and pain from the episiotomy. Numerous analgesics, such as ibuprofen or acetaminophen, could be used to treat episiotomy pain, helping the client achieve comfort and thus fall asleep. Oxytocin is used to contract the uterus.

The nurse is caring for a client on the second postpartum day. The nurse should expect the client's lochia to be red and moderate. continuous with red clots. brown and scant. thin and white.

During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks.

A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority? By discharge, the family will bond with the neonate. The client will demonstrate self-care and infant care by the end of the shift. The client will state instructions for discharge during the first postpartum day. By the end of the shift, the client will describe a safe home environment.

Educating the client about caring for themselves and the infant are the two highest priority goals. Following birth, all birth parents, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed to meet the specific needs of each client. Bonding is significant, but it is only one aspect of the needs of this client, and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for the client and infant and when the nurse determines if there is a need for referrals. Safety is an aspect of education taught continuously by the nurse and should include maternal as well as newborn safety.

An adolescent presents to a community clinic for treatment of vulvar lesions associated with type 2 herpes simplex. Which intervention is appropriate to do at this time? Select all that apply. Notify the adolescent's parents and ask permission to treat their child. Escort the adolescent to a private examination room. Inform the adolescent that confidentiality is not guaranteed. Ask the adolescent if their parents know about their sexual activity. Provide the adolescent with literature about type 2 herpes simplex.

Escort the adolescent to a private examination room. Provide the adolescent with literature about type 2 herpes simplex. The nurse should take the client to an examination room to provide privacy. Laws state that adolescents may obtain treatment for sexually transmitted diseases without parental notification. It is appropriate to provide literature about the disorder to prevent further occurrence. This adolescent is guaranteed the same confidentiality as older clients. It is not appropriate for the nurse to ask the adolescent if their parents know about their sexual activity; doing so could undermine the therapeutic relationship.

In developing a plan of care for the client who has just given birth to a 3175-g (7 lb) baby, the nurse reviews the client's prenatal, labor, and birth records. Which data in the client's record would alert the nurse to the possibility of a problem? perineal laceration white blood cell count of 12,000/mm3 (12 x 109/L) blood loss of 400 ml at birth temperature of 99°F (37.2°C) 1 hour after birth

Evidence of a laceration places the client at risk for a possible infection. A laceration in the perineum may cause localized infection. During pregnancy and the postpartum period, the white blood cell count may be slightly elevated. A blood loss of 400 ml is within normal range. Hemorrhage is denoted as a blood loss of 500 ml or greater. A slight increase in temperature is common 1 hour after birth due to dehydration and will resolve when the client increases fluid intake.

A neonate born at 28 weeks' gestation has been receiving 80% to 100% oxygen via mechanical ventilation for the past 2 weeks. The neonate also has received multiple blood transfusions to treat anemia and has experienced several episodes of apnea. The nurse caring for the neonate should anticipate which iatrogenic complication? retinopathy of prematurity transient tachypnea hyperbilirubinemia neonatal asphyxia

Experts attribute retinopathy of prematurity to high concentrations of administered oxygen and the consequent elevation in the partial pressure of arterial oxygen. However, they suspect that coexisting factors, such as prematurity, blood transfusions, and apnea, must be present. Transient tachypnea is associated with incomplete removal of fetal lung fluid; to treat this problem, oxygen therapy is administered, but mechanical ventilation is used rarely. Hyperbilirubinemia isn't associated with the conditions mentioned in the question. Neonatal asphyxia is associated with hypoxemia, an above-normal partial pressure of arterial carbon dioxide, and decreased blood pH.

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge? lochia alba lochia rubra lochia serosa lochia

For the first 3 days after birth, the discharge is called lochia rubra. It consists almost entirely of blood, with only small particles of decidua and mucus. Lochia alba is a creamy white or colorless discharge that occurs 10 to 14 days postpartum. Lochia serosa is a pink or brownish discharge that occurs 4 to 14 days postpartum. The term lochia alone is not a correct description of the discharge.

The nurse is caring for a newborn of a primiparous client with insulin-dependent diabetes. When the parent visits the neonate at 1 hour after birth, the nurse explains to the parent that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason? increased use of glucose stores during a difficult labor and birth process interrupted supply of maternal glucose and continued high neonatal insulin production a normal response that occurs during the transition from intrauterine to extrauterine life increased pancreatic enzyme production caused by decreased glucose stores

Glucose crosses the placenta, but insulin does not. Hence, a high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin. At birth, the neonate loses the maternal glucose source but continues to produce much insulin, which commonly causes a drop in blood glucose levels (hypoglycemia), usually 30 to 60 minutes after birth. Most neonates do not develop hypoglycemia if their birth parents are not insulin dependent unless they are preterm. Therefore, hypoglycemia is not a normal response as the neonate transitions to extrauterine life.

A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that they want to breast-feed the neonate? Encourage breast-feeding so that the client can get rest and get healthier. Encourage breast-feeding because it's healthier for the neonate. Encourage breast-feeding to facilitate bonding. Discourage breast-feeding because HIV can be transmitted through breast milk.

HIV can be transmitted through breast milk, so breast-feeding should be discouraged in this case.

A client with human papillomavirus (HPV) infection is being treated by a colposcopy. The client asks the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur? infertility cervical cancer pelvic inflammatory disease rectal cancer

HPV infection, or genital warts, can lead to dysplastic changes of the cervix, referred to as cervical intraepithelial neoplasia. The development of cervical cancer remains the largest threat of all condyloma-associated neoplasias. Infertility, pelvic inflammatory disease, and rectal cancer are not complications of genital warts.

What should the nurse expect to find when assessing a premature neonate born at 30 weeks' gestation? firm cartilage to the edge of the ear pinna elbows brought to chest midline with resistance past the midline fine, downy hair over the upper arms and back prominent creases on the soles and heels

Lanugo (fine, downy hair) covers the entire body until about 20 weeks' gestation, when it begins to disappear from the face, trunk, and extremities, in that order. Lanugo is a consistent finding in preterm neonates. Firm cartilage to the edge of the ear pinna is a physical characteristic found in neonates born at term. The ability to bring elbows to the midline of the chest with resistance past midline, also known as the scarf sign, is a physical characteristic found in neonates born at term. At 30 weeks' gestation, there is no resistance, and the elbow can be moved easily past midline. Creases on the soles and heels are physical characteristics found in neonates born at term. A preterm neonate would exhibit few sole creases.

While assessing a neonate weighing 3175 g (3.2 kg) who was born at 39 weeks' gestation to a primiparous client who reports opiate use during pregnancy, the nurse understands that which finding would indicate possible opiate withdrawal? bradycardia high-pitched cry sluggishness hypothermia

Manifestations of opiate withdrawal in the neonate, known as neonatal abstinence syndrome (NAS), include increased central nervous system irritability, which can manifest as a high-pitched cry. Sluggishness or lethargy are not symptoms of NAS. Metabolic, vasomotor, and respiratory disturbances seen with NAS involve tachycardia and fever, not bradycardia or fever. These signs usually appear within 72 hours and persist for several days.

The nurse is developing a community health education program about sexually transmitted infections. Which information about females who acquire gonorrhea should be included? Females are more reluctant than males to seek medical treatment. Gonorrhea is not easily transmitted to those who are menopausal. Females with gonorrhea usually have no symptoms. Gonorrhea is usually a mild disease for females.

Many females who acquire gonorrhea have no symptoms or experience mild symptoms that are easily ignored. They are not necessarily more reluctant than males to seek medical treatment, but they are more likely not to realize they have been affected. Gonorrhea is easily transmitted to all females and can result in serious consequences, such as pelvic inflammatory disease and infertility.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's birth parent tells the nurse that they were planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? Breastfeeding is not recommended because the neonate needs increased fat in the diet. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

Many intensive care units that care for high-risk neonates recommend that the birth parent pump their breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breastfeeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breastfed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breastfeed. During feedings, supplemental oxygen can be delivered by nasal cannula.

A primiparous client is on a regular diet 24 hours postpartum. The client's parent asks the nurse if they can bring some "special foods from home." The nurse responds, based on the understanding of which principle? Foods from home are generally discouraged on the postpartum unit. The parent can bring the client any foods that they desire. This is permissible as long as the foods are nutritious and high in iron. The client's health care provider (HCP) needs to give permission for the foods.

On most postpartum units, clients on regular diets are allowed to eat whatever kinds of food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain the HCP's permission. Although it is preferred, the foods do not necessarily have to be high in iron. In some cultures, there is a belief in the "hot-cold" theory of disease: certain foods (hot) are preferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse should allow the parent to bring the client "special foods from home." Doing so demonstrates cultural sensitivity and aids in developing a trusting relationship.

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's parent asks why the baby's oxygen is humidified. What should the nurse should tell the parent? "The humidity promotes the expansion of the neonate's immature lungs." "The humidity helps to prevent viral or bacterial pneumonia." "Oxygen is drying to the mucous membranes unless it is humidified." "Circulation to the baby's heart is improved with humidified oxygen."

Oxygen should be humidified before administration to help prevent drying of the mucous membranes in the respiratory tract. Drying impedes the normal functioning of cilia in the respiratory tract and predisposes an infant to mucous membrane irritation. Humidification of oxygen does not promote expansion of the immature lungs. Expansion is promoted by placing the infant in a prone position or providing the preterm infant with surfactant medication. Humidified oxygen does not prevent viral or bacterial pneumonia. In fact, in some nurseries, Staphylococcus aureus has been detected in moist environments and on the hands and nails of staff members, predisposing the neonate to pneumonia. Humidified oxygen does not improve blood circulation in the cardiac system.

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on the perineum. However, the perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 0 to 10. Which nursing intervention would be the most appropriate at this time? Begin sitz baths. Administer pain medication per prescription. Replace ice packs on the perineum. Initiate anesthetic sprays to the perineum.

Pain medication is the first strategy to initiate at this pain level. When trauma has occurred in any area, the usual intervention is ice for the first 24 hours and heat after the first 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable.

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98° F (36.6° C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated? Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours. Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures. Arrange a transfer to the neonatal intensive care unit with diagnosis of possible sepsis. Draw a complete blood count (CBC) with differential and feed the infant.

Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures. The concern with this infant is sepsis based on prolonged rupture of membranes before birth. Blood cultures would provide an accurate diagnosis of sepsis but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a respiratory rate greater than 60, grunting, and occasional flaring are not normal. Although not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis, but the changes in the white blood cell levels can identify an infant at risk. Many experts suggest that waiting until an infant is 6 to 12 hours old to draw a CBC will give the most accurate results.

A birth parent with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes the neonate to the neonatal intensive care unit (NICU), places the neonate on an overbed warmer, and provides mechanical ventilation. When the birth parent arrives in the NICU for the first time, the nurse's priority should be to explain the NICU visiting policy for the birth parent and family. enhance bonding by pointing out the neonate's features. obtain a family medical history. question the birth parent about preterm labor.

Pointing out neonate's features to the birth parent enables them to begin to bond with the infant. The nurse should encourage this important activity from the time of the neonate's admission to the NICU. Explaining the NICU visiting policy, obtaining a family medical history, and questioning the birth parent about preterm labor don't take priority over enhancing maternal bonding.

On the second postpartum day, a client tells the nurse that they feel anxious and tearful. Which assessment finding is most consistent with the client's statement? poor coping skills postpartum "blues" postpartum depression postpartum psychosis

Postpartum "blues" are a normal, expected finding 2 days postpartum. About 50% to 70% of postpartum clients experience transient depression during the first 7 to 10 days after giving birth. Postpartum depression and postpartum psychosis aren't seen until later than the second day postpartum. A statement by the client about not being able to care for the neonate or themselves would indicate poor coping skills.

A viable neonate born to a 28-year-old multiparous client by cesarean birth because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which factor would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome? birth parent's development of placenta previa neonate born preterm birth parent receiving analgesia 4 hours before birth neonate with sluggish respiratory efforts after birth

RDS is a developmental condition that primarily affects preterm infants before 35 weeks' gestation because of inadequate lung development from deficient surfactant production. The development of placenta previa has little correlation with the development of RDS. Although excessive analgesia can depress the neonate's respiratory condition if it is given shortly before birth, the scenario presents no information that this has occurred. The neonate's sluggish respiratory activity postpartum is not the likely cause of RDS but may be a sign that the neonate has the condition.

Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which substance? somatotropin surfactant testosterone progesterone

RDS, previously called hyaline membrane disease, is a developmental condition involving a decrease in lung surfactant that leads to improper expansion of the lung alveoli. Surfactant contains a group of surface-active phospholipids, of which one component—lecithin—is the most critical for alveolar stability. Surfactant production peaks at about 35 weeks' gestation. This syndrome primarily attacks preterm neonates, though it can also affect term and postterm neonates. Altered somatotropin secretion is associated with growth disorders such as gigantism or dwarfism. Altered testosterone secretion is associated with masculinization. Altered progesterone secretion is associated with spontaneous abortion during pregnancy.

The newborn nurse has just received the shift report about a group of newborns and is to receive another admission in 30 minutes. To provide the safest care and plan for the new admission, the nurse should do which tasks in order of first to last? All options must be used. 1Review notes from the shift report, and prioritize all clients; make rounds on the most critical first. 2Move quickly from room to room, and assess all clients. 3Log on to the clinical information system, and determine if there are new prescriptions. 4Check the room to which the new client will be admitted to ensure all supplies and equipment are available.

Review notes from the shift report, and prioritize all clients; make rounds on the most critical first. Move quickly from room to room, and assess all clients. Log on to the clinical information system, and determine if there are new prescriptions. Check the room to which the new client will be admitted to ensure all supplies and equipment are available.

A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed their neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? keeping plastic liners in the bra to keep the nipple drier placing as much of the areola as possible into the baby's mouth smoothly pulling the nipple out of the mouth after 10 minutes removing any remaining milk left on the nipple with a soft washcloth

Several methods can be used to prevent nipple soreness. Placing as much of the areola as possible into the neonate's mouth is one method. This action prevents compression of the nipple between the neonate's gums, which can cause nipple soreness. Other methods include changing position with each feeding, avoiding breast engorgement, nursing more frequently, and feeding on demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple soreness. Instead, air drying is recommended. Pulling the baby's mouth out smoothly after only 10 minutes may prevent the baby from receiving the entire feeding and increases nipple soreness. Any breast milk remaining on the nipples should not be wiped off because the milk has healing properties.

A client at 4 weeks postpartum tells the nurse that they cannot cope any longer and are overwhelmed by their newborn. The baby has old infant formula staining the clothes and under the neck. The client does not remember when they last bathed the baby and states they do not want to care for the infant. The nurse should encourage the client and spouse to call their health care provider (HCP) because the client should be evaluated further for which complication? postpartum blues postpartum depression poor bonding infant abuse

The client is experiencing and verbalizing signs of postpartum depression, which usually appears at about 4 weeks postpartum but can occur at any time within the first year after birth. It is more severe and lasts longer than postpartum blues, also called "baby blues." Baby blues are the mildest form of depression and are seen in the latter part of the first week after birth. Symptoms usually disappear shortly. Depression may last several years and is disabling to the client. Poor bonding may be seen at any time but commonly becomes evident as the client begins interacting with the infant shortly after birth. Infant abuse may take the form of neglect or injuries to the infant. A depressed birth parent is at risk for injuring or abusing their infant.

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage? hypertension uterine infection placenta previa severe pain

The client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta previa, the lower uterine segment doesn't contract as well as the fundal part of the uterus; therefore, more bleeding occurs. Hypertension, severe pain, and uterine infection don't increase the client's risk for postpartum hemorrhage.

A neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The parent visits the nursery soon after the neonate is admitted. Which instructions should the nurse expect to include when developing the teaching plan for the parent about FAS? Withdrawal symptoms usually do not occur until 7 days after birth. Large-for-gestational-age size is common with this condition. Facial deformities associated with FAS can be corrected by plastic surgery. Symptoms of withdrawal include tremors, sleeplessness, and seizures.

The long-term prognosis for neonates with FAS is poor. Symptoms of withdrawal include tremors, sleeplessness, seizures, abdominal distention, hyperactivity, and inconsolable crying. Symptoms of withdrawal commonly occur within 6 to 12 hours or, at the latest, within the first 3 days of life. The neonate with FAS usually has a growth deficiency at birth. Most neonates with FAS have intellectual disability that ranges from mild to severe. The facial deformities associated with FAS, such as short palpebral fissures; epicanthal folds; a broad nasal bridge; a flattened midface; and a short, upturned nose; are not easily corrected with plastic surgery.

The nurse cares for several preterm infants in the special care nursery. Which action is most important for preventing nosocomial infections in these neonates? using sterile supplies for all treatments performing thorough handwashing before giving infant care donning cover gowns for nurses and visitors to the unit wearing a mask, and changing it frequently when giving care

The number one cause of nosocomial infections in hospital units is not washing the hands. Nosocomial infections can be significantly reduced by thorough handwashing before caring for each infant. Sterile supplies are not necessary for all treatments. Cover gowns and masks, though helpful in reducing the risk for exposure to blood and body fluids, do not decrease the risk for nosocomial infection.

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take? Ask the client to get out of bed and try to urinate. Call the health care provider for a methylergonovine order. Assess the fundus and massage it if it's boggy. Give the client a new pad and check them in 30 minutes.

The nurse should first asses the fundus to determine if clots are present or if uterine involution has occurred. Clots, no uterine involution, and the saturation of two perineal pads within 30 minutes could indicate postpartum hemorrhage. If the fundus is boggy, massaging it will suppress bleeding by encouraging the uterus to contract upon itself and the open vessels that were attached to the placenta. Massaging also helps to expel clots or tissue remaining from the birth. If the nurse assesses a firm fundus, the nurse should next assess for a full bladder and then ask the client to try to urinate. If the uterus remains boggy after massage, the nurse should obtain an order from the health care provider for methylergonovine. Waiting 30 minutes without intervening could contribute to uterine hemorrhage.

The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new birth parent has a midline episiotomy. Which finding by the nurse would warrant further assessment? distended vaginal tissue edema around the episiotomy site two perineal pads soaked with blood within 30 minutes tenderness around the episiotomy site

Two perineal pads soaked within 30 minutes may be indicative of early postpartum hemorrhage and warrant further investigation. The most frequent cause of early postpartum hemorrhage is uterine atony or a "boggy fundus." The nurse should gently massage the fundus and call for assistance if heavy bleeding continues. Distended vaginal tissue is a normal finding. Edema around the episiotomy is a normal finding. Tenderness and soreness around the episiotomy site are normal once the anesthesia has worn off.

The nurse is caring for a 22-year-old gravida 2, para 2 client who has disseminated intravascular coagulation after the birth of a dead fetus. Which finding is the highest priority to report to the health care provider (HCP)? activated partial thromboplastin time (APTT) of 30 seconds hemoglobin of 11.5g /dL (115 g/L) urinary output of 25 mL in the past hour platelets at 149,000/mm3 (149 x 109/L)

Urinary output of less than 30 mL per hour indicates renal compromise and would be the most important assessment finding to report to the HCP. The APTT is within normal limits, and the hemoglobin is lower than values for an adult client but within normal limits for a pregnant client. Although the platelet level is slightly low and may impact blood clotting, when compared to renal failure, it is less important.

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What action should the nurse take first? Gently massage the fundus. Assess the client for infection. Determine if the uterus has ruptured. Increase the intravenous fluid rate.

Uterine atony means that the uterus is not firm because it is not contracting. First, the nurse should gently massage the uterus in an effort to help contract the uterus and make it firm. Clients with multiple gestation, polyhydramnios, prolonged labor, or a large-for-gestational-age fetus are more prone to uterine atony. Assessing for infection is inappropriate because postpartum infection is not associated with uterine atony. Determining if the uterus has ruptured is inappropriate because uterine atony is not a sign of uterine rupture. Increasing the intravenous fluid rate may be prescribed if the client develops symptoms of shock.

During the fourth stage of labor, the client should be assessed carefully for uterine atony. complete cervical dilation. placental expulsion. umbilical cord prolapse.

Uterine atony should be carefully assessed during the fourth stage. The second stage of labor begins with complete cervical dilation and ends with birth. The third stage begins immediately after birth and ends with the separation and expulsion of the placenta. Immediately after delivery, the placenta is evaluated carefully for completeness, and the client is assessed for excessive bleeding or a relaxed uterus. After delivery of the placenta is the fourth stage and assessing for relaxed uterus helps determine uterine atony. Umbilical cord prolapse, displacement of the umbilical cord to a position at or below the fetus's presenting part, occurs most commonly when amniotic membranes rupture before fetal descent. The client should be assessed for a visible or palpable umbilical cord in the birth canal, violent fetal activity, or fetal bradycardia with variable deceleration during contractions. The presence of umbilical cord prolapse requires an emergency delivery.

A client is 9 days postpartum and breast-feeding the neonate. The client experiences pain, redness, and swelling of the left breast and is diagnosed with mastitis. The nurse teaching the client how to care for the infected breast should include which information? Wear a loose-fitting bra to avoid constricting the milk ducts. Stop breast-feeding permanently. Take antibiotics until the pain is relieved. Use a warm moist compress over the painful area.

Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The client with mastitis should wear a proper fitting bra with good support. Breast-feeding does not have to be interrupted. The client will also need to pump the breast to keep the breast empty of milk and to ensure an adequate milk supply. Adequate emptying of the affected breast helps prevent more bacteria from collecting in the breast and may shorten the duration of the infection. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.

A client has just given birth to their first, healthy, full-term neonate. The client is Rho(D)-negative and the neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? Administration of Rho(D) immune globulin I.M. to the neonate within 72 hours Administration of Rho(D) immune globulin I.M. to the parent within 72 hours Injection of Rho(D) immune globulin to the parent during their 6 week follow-up visit Administration of Rho(D) immune globulin I.M. to the parent within 3 months

When a birth parent is Rho(D)-negative and a neonate is Rh-positive, the parent forms antibodies against the D antigen. Most of the antibodies develop within the first 72 hours after giving birth as a result of the exchange of maternal and fetal blood during birth. If the parent becomes pregnant again, the parent will have a high antibody D level that may destroy fetal blood cells during the second pregnancy. However, if the parent receives an injection of Rho(D) immune globulin within 72 hours, no antibodies will be formed. Rho(D) immune globulin may also be given to the parent during pregnancy if the neonate is Rh-positive. The neonate isn't given Rho(D) immune globulin.

A preterm neonate is having frequent blood draws for laboratory specimens. What is most important for the nurse to document about the blood draws? amount of blood drawn for each specimen color of the blood in the specimen container vital signs before each blood draw time of the last feeding before each specimen

When repeated blood specimens are obtained from a preterm neonate, keeping a record of the amount of blood taken for each specimen is essential. The total blood volume of a preterm neonate is small, and repeated blood collections can deplete blood volume. A record of the amount of blood taken for specimens is a guide to help determine if the neonate needs a transfusion. Vital signs and the color of the specimen are not reliable indicators of the neonate's blood volume. The time of the last feeding may be related to glucose levels, not blood volume.

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? retained placental tissue uterine inversion bladder distention perineal lacerations

perineal lacerations A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case, the fundus would be soft, possibly boggy, and displaced from the midline.