OB 5
Which patient has the most risk for postpartum hemorrhage? a. Primigravida who delivered a 6lb 3oz girl b. Gravida 2 who delivered a 8 lb 6 oz boy c. Gravida 3 who delivered twins, 5lb, 3oz and 4lb, 2oz d. Gravida 3 who delivered a 4lb, 3oz boy
ANS: C
Ellen's newborn was born weighing 2576gms. On day 2 of life, the baby weighed 2345 gms. What percentage of weight loss did the baby experience? Round to the hundredths place
ANS: 8.97% Step 1 → 2576-2345=231 Step 2→ 231/2576 {original birth weight} =0.089673 Step 3 → 0.089673 x 100 {to get percentage value} = 8.96[1] 73 Hundredths place
A 37-year-old gravid 8 para 7 woman is admitted to the postpartum unit at 2 hours post-birth. On admission to the unit, her fundus was U/U, midline,, and firm, and her lochia is moderate rubra. And hour later, her fundus is shifter from midline and boggy, and the lochia is heavier. The nurse massages the fundus of the uterus and determines that the next logical nursing action is to: a. Assis the woman to the bathroom and reassess the fundus b. Continue to massage the uterus for 5-10 minutes c. Notify physicians of midwife d. Start IV oxytocin therapy as per standing orders
ANS: A
A 37-year-old gravida 8 para 7 woman is admitted to the postpartum unit at 2 hours post-birth. On admission to the unit, her fundus was U/U, midline,, and firm, and her lochia is moderate rubra. An hour later, her fundus is shifter from midline and boggy, and the lochia is heavier. The nurse massages the fundus of the uterus and determines that the next logical nursing action is to: a. Assist the woman to the bathroom and reassess the fundus b. Continue to massage the uterus for 5-10 minutes c. Notify physicians of midwife d. Start IV oxytocin therapy as per standing orders
ANS: A
The nurse is providing discharge counseling to a woman who is breastfeeding her baby. The nurse advises the woman that if she experiences unilateral breast pain, inflammation, and fever, she should do which of the following? a. Contact her physician or nurse midwife {rationale: mastitis} b. Consume an herbal galactagogue c. Bottle feed the baby during the next day d. Take expressed breast milk to the laboratory
ANS: A
Which data in the patient's history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression? a. Previous depressive episode b. Unexpected operative birth c. Ambivalence during the first-trimester d. Second pregnancy in a 3-year period
ANS: A A personal or family history of depression or other mental illness is a risk factor for postpartum depression. An operative birth, ambivalence during the first trimester, and two pregnancies in 3 years are not risk factors for postpartum depression.
A new father calls the nurse's station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, "She was never like this before the baby was born." How should the nurse best respond? a. Reassure him that this behavior is normal. b. Advise him to get immediate psychological help for her. c. Tell him to ignore the mood swings because they will go away. d. Instruct him in the signs, symptoms, and duration of postpartum blues.
ANS: A Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. Postpartum blues are a normal process that is short-lived; no medical intervention is needed. Telling him to ignore the moods blocks communication and may belittle the husband's concerns. Patient teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching
Which measure may prevent mastitis in breastfeeding clients? a. Initiating early and frequent breastfeedings b. Wearing a tight-fitting bra c. Applying ice pack prior to feeding d. Nursing the infant for 5 minutes on each breast
ANS: A Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. Five minutes does not empty the breast adequately. This will produce stasis of the milk. A firm-fitting bra will support the breast, but not prevent mastitis. The breast should not be bound. Warm packs before feeding will increase the flow of milk.
The nurse thoroughly dries the infant immediately after birth primarily to a. reduce heat loss from evaporation. b. stimulate crying and lung expansion. c. increase blood supply to the hands and feet. d. remove maternal blood from the skin surface.
ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood
Which patient data received during report should the nurse recognize as being at risk for postpartum complications? a. Gravida 5, para 5 b. Labor duration of 4 hours c. Infant weight greater than 3800 g d. Epidural anesthesia for labor and birth
ANS: A Multiparity (five or more deliveries) is a risk factor for postpartum uterine atony and hemorrhage. A labor duration of 4 hours is not a risk factor because it is not a precipitate labor and birth (less than 3 hours), infant weight of 3800 g is not a risk factor because the infant is not macrosomic, and epidural anesthesia is not a risk factor because epidural anesthesia does not affect uterine contractions.
For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to a. 6:30 AM on January 13. b. 6:30 PM on January 13. c. 6:30 PM on January 14. d. 6:30 AM on January 15.
ANS: A Rho(D) immune globulin (RhoGAM) must be administered within 72 hours after the birth of an Rh-positive infant. 6:30 PM on January 13, 6:30 PM on January 14, and 6:30 AM on January 15 do not fall within the established timeframe.
The nurse is assessing a newborn immediately after birth. After assigning the first Apgar score of 9, the nurse notes two vessels in the umbilical cord. What is the nurse's next action? a. Assess for other abnormalities of the infant. b. Note the assessment finding in the infant's chart. c. Notify the health care provider of the assessment finding. d. Call for the neonatal resuscitation team to attend the infant immediately.
ANS: A The normal finding in the umbilical cord is two arteries and one vein. Two vessels may indicate other fetal anomalies. Notation of the finding is the appropriate next step when the finding is expected. The health care provider will need to be notified; however, the infant is the nurse's primary concern and must be assessed for abnormalities first. The initial Apgar score is 9, indicating no signs of distress or need of resuscitation.
The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction.
ANS: A The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborn's palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the clunk of hip dysplasia when the femoral head moves in the hip socket.
A newborn is admitted to the newborn nursery with hypothermia. Which complication should the nurse monitor related to hypothermia in the newborn? Select all that apply a. Hypoglycemia b. Respiratory distress c. Vasodilation of peripheral blood vessels d. Hyperglycemia
ANS: A AND B
The importance of a Neutral Thermal Environment for the newborn is to (check all that apply) a. Minimize the need for increased oxygen consumption b. Minimize the use of calories to maintain body heat within the temperature range of 36.4C-37.2C c. To have higher APGAR scores by preventing the infant's color from becoming blue d. To prevent metabolic acidosis
ANS: A, B AND D
The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.) a. Offer the patient a warm blanket. b. Place an ice pack on the perineum. c. Massage the uterus if it is boggy. d. Delay breastfeeding until the patient is rested. e. Explain to the patient that the lochia will be light pink in color.
ANS: A, B, C The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will be bright red not pink.
Which vaccinations are indicated for the postpartum patient if she does not have immunity? (Select all that apply.) a. Pertussis b Rubella c. Diphtheria, tetanus (Tdap) d. RhoGAM e. Varicella
ANS: A, B, C, E If a patient who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, Tdap, and varicella should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results
The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) a. Low-set ears b. Yellow sclera c. A doll's eye sign d. Edema of the eyelids e. Absence of the grasp reflex
ANS: A, B, E Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic problem. The doll's eye sign is a normal finding in the newborn; when the head is turned quickly to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which causes capillary rupture in the sclera.
Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply.) a. Insufficient emptying b. Feeding every 2 hours c. Supplementing feedings d. Blisters on both nipples e. Alternating breastfeeding positions
ANS: A, C, D Mastitis may develop because of stasis of milk, inadequate emptying of the breast, skipped feedings, and introduction of bacteria through injured areas of the nipple. Feeding every 2 hours and alternating breastfeeding positions are both interventions that promote emptying of the breasts and support successful breastfeeding.
The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include which of the following? (Select all that apply.) a. Anemia b. Dehydration c. Exhaustion d. Postpartum infection e. Failure to attach to her infant
ANS: A, C, D, E Postpartum hemorrhage often results in anemia, and iron therapy may need to be initiated. Exhaustion is common after hemorrhage. It may take the new patient weeks to feel like herself again. Fatigue may interfere with normal parent-infant bonding and the attachment processes. The patient is likely to require assistance with housework and infant care. Excessive blood loss increases the risk for infection. The excessive blood loss that this patient has experienced is likely to lead to risk for infection rather than dehydration. It is important that all mothers be educated about adequate fluid intake after birth.
A Patent Ductus Arteriosus (select all of the apply) a. Affects more girls than boys b. Is a persistent blood flow between the aorta and pulmonary artery that causes the blood to circulate between the heart and lungs c. Should close within hours after birth d. Signs and symptoms includes blueish color of the fingertips, toes and mouth e. Is common in premies
ANS: A,B,C,E
Which newborn is at higher risk for developing hypoglycemia? (Select all that apply) a. Post-term newborn b. 38 weeks gestation newborn c. Small for gestational age newborn provided d. Large for gestational age newborn e. Term newborn by cesarean birth
ANS: A,C,D
Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period following cesarean birth? a. Limit the client's oral intake of fluids for the first 24 hours B. Assist the client in performing leg exercises every 2 hours c. Ambulate the client as soon as her vital signs are stable d. Rill a bath blanket and place it firmly behind the client's knees
ANS: B
A postpartum patient would be at increased risk for postpartum hemorrhage if she delivered a(n) a. 5-lb, 2-oz infant with outlet forceps. b. 6.5-lb infant after a 2-hour labor. c. 7-lb infant after an 8-hour labor. d. 8-lb infant after a 12-hour labor.
ANS: B A rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction. Delivering a 5-lb, 2-oz infant with outlet forceps would put this patient at risk for lacerations due to the use of forceps. A 7-lb infant after an 8-hour labor is a normal labor progression. Less than 3 hours is considered a rapid labor and can produce uterine muscle exhaustion. An 8-lb infant after a 12-hour labor is a normal labor progression. Less than 3 hours is a rapid birth and may cause the uterine muscles failure to contract.
The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 10 to 15 cm (4- to 6-inch) stain on the peripad c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad d. Less than a 1-inch stain on the peripad
ANS: B Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: • Scant—less than 2.5 cm (1-inch) stain on the peripad • Light—less than a 10 cm (4 inch) stain • Moderate—less than a 15 cm (6 inch) stain • Heavy—saturated peripad • Excessive—saturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery.
Infants who develop cephalohematoma are at an increased risk for a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.
ANS: B Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that is sometimes referred to as "fleabite rash."
A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely? a. Hyperglycemia b. Metabolic acidosis c. Respiratory acidosis d. Vasodilation of peripheral blood vessels
ANS: B Cold stress can cause a significant rise in oxygen demands. Metabolism of glucose in the presence of insufficient oxygen causes increased production of acids. Metabolism of brown fat also releases fatty acids. The result can be metabolic acidosis, which can be a life-threatening condition. Cold stress causes hypoglycemia because glucose is being metabolized. Cold stress does not cause respiratory acidosis. As the infant's body attempts to conserve heat, vasoconstriction, not vasodilation, of the peripheral blood vessels occurs to reduce heat loss from the skin surface
Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands? a. Radiation b. Conduction c. Convection d. Evaporation
ANS: B Conduction occurs when the infant comes in contact with cold objects. Radiation is the transfer of heat to a cooler object that is not in direct contact with the infant. Convection occurs when heat is transferred to the air surrounding the infant. Evaporation can occur during birth or bathing as a result of wet linens or clothes, or insensible heat loss.
The nurse understands that late postpartum hemorrhage may be prevented by a. manually removing the placenta. b. inspecting the placenta after birth. c. administering broad-spectrum antibiotics. d. pulling on the umbilical cord to hasten the birth of the placenta.
ANS: B If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Manual removal of the placenta increases the risk of postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.
The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic jaundice is that nonphysiologic jaundice a. may result in kernicterus. b. appears during the first 24 hours of life. c. begins on the head and progresses down the body. d. results from the breakdown of excessive erythrocytes not needed after birth.
ANS: B Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. This type of jaundice may lead to kernicterus; however, screening and appropriate treatment needs to take place in a time sensitive manner in order to prevent kernicterus. Jaundice proceeds from the head down. Both jaundices are the result of the breakdown of erythrocytes. Nonphysiologic jaundice is caused by an underlying condition, such as Rh incompatibility
When assessing the A of the acronym REEDA, the nurse should evaluate the a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge.
ANS: C In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage.
A patient has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus. The patient now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to a. evaluate intake and output of the past 12 hours following birth. b. initiate a rapid response intervention. c. obtain an order from the physician for type and crossmatch of 2 units packed red blood cells (PRBCs). d. reposition the patient and reassess in 15 minutes. Initiate frequent vital sign assessments.
ANS: B Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the recent patient history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the patient's complaints of difficulty breathing suggest that the patient is progressing to pulmonary edema. An appropriate intervention is to initiate a rapid response intervention so that the patient can be stabilized. Calling the physician for a type and crossmatch order is not indicated. Repositioning the patient, even with the initiation of frequent vital signs, will not treat the emerging clinical condition. Evaluation of intake and output, although necessary, is not the priority nursing action at this time.
Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 21°C (70°F). b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly.
ANS: B Padding the scale prevents heat loss from the infant to a cold surface by conduction. The room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Hourly assessments are not necessary for a normal newborn with a stable temperature. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature by convection.
Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.
ANS: B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.
A patient with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse? a. Organisms will be inactivated by gastric acid. b. Organisms that cause mastitis are not passed through the milk. c. The infant is not susceptible to the organisms that cause mastitis. d. The infant is protected from infection by immunoglobulins in the breast milk.
ANS: B The organisms are localized in the breast tissue and are not excreted in the breast milk. The organism will not get into the infant's gastrointestinal system. Because of an immature immune system, infants are susceptible to many infections; however, this infection is in the breast tissue and is not excreted in the breast milk. The patient is just producing the immunoglobulin from this infection, so it is not available for the infant.
Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority? a. Notify the clinician stat. b. Test for the blood glucose level. c. Start an intravenous line with D10W. d. Document the event in the nurses' notes.
ANS: B These symptoms are indications of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain. It is not common practice to administer intravenous glucose to a newborn unless their condition does not allow for enteral feedings. Feeding the infant is preferable as formula or breast milk will maintain glucose stability. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present.
Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the primary indication for the administration of vitamin K? a. "The nurse will draw blood to determine if vitamin K is needed." b. "Vitamin K prevents the possibility of bleeding problems in my baby." c. "My baby will receive medication by mouth when the nurse administers the vitamin K." d. "Vitamin K will be administered shortly after birth, generally within the first hour."
ANS: B This indication is the reason for vitamin K administration. Vitamin K is given to neonates because they cannot synthesize it in the intestines without bacterial flora. This places them at risk for hemorrhagic disease of the newborn (vitamin K deficiency disease). One dose of vitamin K intramuscularly after birth prevents bleeding problems until the infant is able to produce vitamin K in sufficient amounts. Vitamin K is not routinely given by mouth. Although the injection is usually given within the first hour after birth, it can be delayed until the infant has finished breastfeeding shortly after birth.
The nurse is explaining fetal circulation to a group of nursing students. Which information should be included in the teaching session? (Select all that apply.) a. After birth the ductus venosus remains open, but the other shunts close. b. The foramen ovale shunts blood from the right atrium to the left atrium c. The ductus venosus shunts blood from the liver to the inferior vena cava. d. The ductus arteriosus shunts blood from the right ventricle to the left ventricle.
ANS: B, C The foramen ovale shunts oxygenated blood from the right atrium to the left atrium, bypassing the lungs. The ductus venosus shunts oxygenated blood from the liver to the inferior vena cava. All shunts close after birth. The ductus arteriosus shunts blood from the right ventricle to the aorta.
Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer. b. Dry the infant off with sterile towels. c. Place stockinette cap on infant's head. d. Bathe the newborn within 30 minutes of birth. e. Remove wet linen as needed.
ANS: B, C, E Following birth, the newborn is at risk for hypothermia. Therefore nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant's head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period
A mother is at high risk for thromboembolic disease in the postpartum period. Select all the reasons that may put a mother at high risk for clot formation. a. Walking around during labor b. Prolonged period of time in the stirrups for birth and repair c. The elevated levels of coagulation factors during pregnancy d. Cesarean birth
ANS: B,C,D
Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply) a. Place the infant covered with blankets in the radiant warmer b. Dry the infant off with towels c. Place stockinette cap on infant's head d. Bath the newborn within 30 mins of birth e. Remove wet linens
ANS: B,C,E
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98% b. The baby with apgar 9/9, weight 2960grams c. The baby with temperature 96.3F, length 17 inches {rationale: hypothermic} d. The baby with glucose 60 mg/dL heart rate 132
ANS: C
Which of the following neonates is at high risk for cold stress? a. A 36 gestational week LGS neonate b. A 32 gestational week AGA neonate c. A 33 gestational week SGA neonate d. A 38 week gestational week AGA neonate
ANS: C
Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the a. direct Coombs test of twin A. b. direct Coombs test of twin B. c. indirect Coombs test of the mother. d. transcutaneous bilirubin level for both twins.
ANS: C Administration of RhoGAM is based on the results of the indirect Coombs test on the patient. A negative result confirms that the mother has not been sensitized by the positive Rh factor of twin A and that RhoGAM is indicated. A direct Coombs test is a diagnostic test used to determine maternal antibodies in fetal blood and to guide treatment of the newborn when Rh and ABO incompatibilities occur. Transcutaneous bilirubin is a noninvasive measure to determine the level of bilirubin in a newborn.
A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered? a.Magnesium sulfate b. Prostaglandin suppository c.RhoGAM if the patient is Rh-negative d. Betamethasone
ANS: C CVS can increase the likelihood of Rh sensitization if a woman is Rh-negative. There is no indication for magnesium sulfate because it is used to stop preterm labor. There is no indication for administration of a prostaglandin suppository. Betamethasone is given to pregnant women in preterm labor to improve fetal lung maturity.
The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as a. albumin binding. b. enterohepatic circuit. c. conjugation of bilirubin. d. deconjugation of bilirubin.
ANS: C Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. Albumin binding attaches something to a protein molecule. Enterohepatic circuit is the route whereby part of the bile produced by the liver enters the intestine, is resorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat-soluble
The nurse observes the patient as she ambulates to the bathroom. Which clinical finding might indicate development of a DVT (deep vein thrombosis)? a. Slow gait b. Shuffling gait c. Stiffness of right leg d. Leans on husband for support
ANS: C Deep vein thrombosis may cause pain on ambulation and stiffness of the affected leg. A slow gait, shuffling gait, and needing ambulatory support are common observations of the postpartum patient because of weakness and discomfort of the perineum.
The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? A .Pulse rate of 50 b. Temperature of 38°C (100.4°F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position
ANS: C Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38°C (100.4°F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.
A postpartum patient has developed deep vein thrombosis (DVT) and treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen? a. Fresh fruits b. Milk c. Lentils d. Soda
ANS: C Foods that are high in vitamin K should be restricted and/or limited in consumption while on Coumadin therapy. Vitamin K is the antidote to Coumadin activity.
The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn? a. Newborns shiver to generate heat. b. Newborns have decreased oxygen demands. c. Newborns have increased glucose demands. d. Newborns have a decreased metabolic rate.
ANS: C In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia.
Which newborn should the nurse recognize as being at the greatest risk for developing respiratory distress syndrome? a. A 35-week-gestation male baby born vaginally to a mother addicted to heroin. b. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes. c. A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes. d. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension.
ANS: C Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension is at risk for hypoxia.
After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. What would increase the nurse's concern about this risk? a. Hypovolemia b. Iron deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency
ANS: C Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site.
After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. Which clinical finding would increase the nurse's concern regarding this risk? a. Hypovolemia b. Iron-deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency
ANS: C Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site.
Which statement regarding newborns classified as small for gestational age (SGA) is accurate? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. They are below the tenth percentile on gestational growth charts. d. Placental malfunction is the only recognized cause of this condition.
ANS: C SGA infants are defined as below the tenth percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are classified as preterm. There are many factors that contribute to the development of an SGA infant, not just placental malfunction.
The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which statement is important to understand regarding the properties of vitamin K? a. It is necessary for the production of platelets. b. It is important for the production of red blood cells. c. It is not initially synthesized because of a sterile bowel at birth. d. It 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. The platelet count in term of newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. Vitamin K is important for blood clotting. Vitamin K is necessary to activate the clotting factors.
A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is a. soft and supple skin. b. a hematocrit level of 55%. c. lack of subcutaneous fat. d. an abundance of vernix caseosa.
ANS: C This post-term infant has actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant.
A steady trickle of bright red blood from the vagina in the presence of firm fundus suggest: a. Perineal hematoma b. Uterine atony c. Lacerations of the genital tract d. Infection of the uterus
ANS: C Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations will not be affected by uterine contraction. The fundus would be boggy with a clinical finding of uterine atony. A hematoma would occur internally with swelling and discoloration. With an infection of the uterus, there would be an odor to the lochia and systemic symptoms such as fever and malaise.
A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight? a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th
ANS: C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant in less than the 10th percentile is small for gestational age.
A nurse is preparing to administer RhoGam to a client who delivered a fetal demise.Which of the following must the nurse check before giving the injections? a. Verify that the direct Coombs test results are positive b. Check that the fetus was at least 28 weeks gestation c. Make sure that the client is at least 3 days post delivery d. Confirm that the client is RH negative
ANS: D
During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels? a. Increased pulmonary vascular resistance b. Decreased systemic resistance c. Decreased pressure in the left heart d. Dilation of pulmonary vessels
ANS: D
If a late postpartum hemorrhage is documented on a patient who delivered 3 days ago, the nurse recognizes that this hemorrhage occurred a. on the first postpartum day. b. during recovery phase of labor. c. during the third stage of labor. d. on the second postpartum day.
ANS: D A late postpartum hemorrhage occurs after the first 24 hours and up to 12 weeks after birth. The first postpartum day, during the recovery phase, and during the third stage are all within the first 24 hours after birth and would be classified as early postpartum hemorrhage.
A breastfeeding patient who was discharged yesterday calls to ask about a tender hard area on her right breast. What should the nurse's first response be? a. "This is a normal response in breastfeeding mothers." b. "Notify your doctor so he can start you on antibiotics." c. "Stop breastfeeding because you probably have an infection." d. "Try massaging the area and apply heat; it is probably a plugged duct."
ANS: D A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area. Massage of the area followed by heat will cause the duct to open. This is a normal deviation but requires intervention to prevent further complications. Tender hard areas are not the signs of an infection, so antibiotics are not indicated. Fatigue, aching muscles, fever, chills, malaise, and headache are signs of mastitis. She may have a localized area of redness and inflammation.
Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba
ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.
Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection
ANS: D Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth.
If a DVT (deep vein thrombosis) is suspected, the nurse should a. perform a Homans sign on the affected leg. b. dorsiflex the foot of the affected leg. c. palpate the affected leg for edema and pain. d. place the patient on bed rest, with the affected leg elevated.
ANS: D Initial treatment of DVT is bed rest with the leg elevated to decrease swelling and promote venous return. Performing a Homans sign, dorsiflexing the foot, and palpating the leg are contraindicated actions that may dislodge a DVT and result in a pulmonary embolism.
A multiparous patient arrives to the labor unit and urgently states, "The baby is coming RIGHT NOW!" The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action? a. Dry the baby off. b. Turn up the temperature in the patient's room. c. Pour warmed water over the baby immediately after birth. d. Place the baby on the patient's abdomen after the cord is cut.
ANS: D Movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin. Placing infants on cold surfaces or touching them with cool objects causes this type of heat loss. The reverse is also true; contact with warm objects increases body heat by conduction. Warming objects that will touch the infant or placing the unclothed infant against the mother's skin (skin to skin) helps prevent conductive heat loss. Drying the baby off helps prevent heat loss through evaporation. Adjusting the temperature in the patient's room helps with heat loss through convection. Pouring warm water over a baby occurs with the first bath, which is conducted after the baby's temperature has stabilized. Pouring warm water over the baby prior to that time will increase heat loss through evaporation.
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's most appropriate response at this time? a. "When did these symptoms begin?" b. "Sounds like normal postpartum depression." c. "Are you having trouble getting enough sleep?" d. "Are you able to get out of bed and provide care for your baby?"
ANS: D Postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management for full recovery. Nurses need to assess the depression to ascertain if she is unable to cope with daily life. Postpartum blues are self-limiting and frequently occur by the fifth postpartum day and resolve in 2 weeks. The response "Sounds like postpartum depression" does not offer the patient any help or encouragement through this challenging time. Asking if she is getting enough sleep does not add to the assessments already identified in the stem. Enough information exists to determine that she has the signs and symptoms of postpartum blues. The nurse must differentiate between postpartum blues and depression.
In comparison with the term infant, the preterm infant has a. more subcutaneous fat. b. well-developed flexor muscles. c. few blood vessels visible through the skin. d. greater surface area in proportion to weight.
ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are features that are more characteristic of a term infant.
Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is optimal for the newborn? a. Deltoid muscle b. Gluteal muscle c. Rectus femoris muscle d. Vastus lateralis muscle
ANS: D The vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels. Gluteal muscles are not used until a child has been walking for at least 1 year to develop these muscles. The rectus femoris is used only if absolutely necessary because this muscle is located closer to the sciatic nerve and blood vessels, which poses a greater danger. The deltoid is not a recommended site for newborn injections
An infant's temperature is recorded at 36°C (96.8°F) during the morning assessment. Which action should the nurse take? a. Note the findings in the electronic health record (EHR). b. Unwrap the infant and inspect for abnormalities. c. Provide the infant with glucose water. d. Make sure that the infant is wrapped securely with a blanket and recheck temperature in 15 minutes.
ANS: D This temperature potentially indicates hypothermia, so the infant should be wrapped securely in a blanket and reassessed after that intervention. Findings should be documented in the EHR; however, this is not the priority intervention. Unwrapping the infant would lead to further compromise and additional risk for the core temperature to drop. Feeding the infant with glucose water may eventually be used as an intervention if the infant shows additional signs of hypoglycemia, which may accompany hypothermia.
Which infant has the lowest risk of developing high levels of bilirubin? a. The infant who is breastfed during the first hour of life b. The infant who was bruised during a difficult birth c. An A+ infant of an O+ mom d. The infant who developed a cephalohematoma
ANS:A
A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediate intervention? a. Itching of the palms and feet b. Nausea c. Urinary output of 300 mL in the past 4 hours d. Respiratory rate of 6 breaths/minute
ANS:D
A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform? a. Supervise all infant care b. Maintain client on strict bed rest c. Restrict visitation to her partner d. Carefully monitor toileting
Ans: A
Marcela is a 32 year old G4P4 who delivered a 4300 Gm infant 2 hours ago. Marcela's prenatal history includes A+, HIV, GC, Chlamydia are all negative; RPR nonreactive; GBS positive, and history of bipolar illness. Marcela's CBC includes WBC 8.0, RBC 3.0, hgb 9.0, hct 33% and platelets 130,000. Based on this information what is this baby at risk for? What are your top nursing priorities, with this infant? What assessment testing shold be ordered on this baby?
Ans: the baby is at risk for sepsis (GBS+) and clavicular fractures and brachial plexus injury due to LGA. The baby is also at risk for hypoglycemia (jittery, low body temp) and for infection (low temperature, poor feed). Assess clavicles and bilateral arm movement. Assess clavicles and bilateral arm movement. Assess skin color for jaundice. Assessment testing includes CBC and blood sugar, possible x-ray.
Marcela is a 32 year old G4P4 who delivered a 4300 Gm infant 2 hours ago. Marcela's prenatal history includes A+, HIV, GC, Chlamydia are all negative; RPR nonreactive; GBS positive, and history of bipolar illness. Marcela's CBC includes WBC 8.0, RBC 3.0, hgb 9.0, hct 33% and platelets 130,000. Based on this information what is she at risk for? What are your top nursing priorities, with this pt? What assessment testing should be ordered on her?
psych referral or evaluation for mom due to bipolar disorder. Macrosomia risk for hemorrhaging. GBS positive needs prophylactic antibiotics such as penicillin/vancomycin. Hgb is low assess for anemia, exhaustion and will see signs of shock in case of hemorrhage.
