OB 7

The nursing instructor is teaching a session on the birth process. During which stage does the woman's cardiac output increase 80% above the pre-labor level? First stage Pushing Immediately after birth Transition stage

Immediately after birth Explanation: Due to an increased demand for oxygen the cardiac output increases up to 80% immediately after birth. During the first stage of labor there is a moderate increase in the demand for oxygen. While pushing, cardiac output can increase by 40% to 50%. During transition, changes are more psychological than physiologic.

A nurse is caring for a pregnant client during labor. Which methods should the nurse use to provide comfort to the pregnant client? Select all that apply. hand holding chewing gum massaging acupressure prescribed pain killers

hand holding massaging acupressure

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 day after birth After the newborn has completed the antibiotic therapy Before discharge from the hospital 1 month after discharge

After the newborn has completed the antibiotic therapy Explanation: It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery? Test the newborn for HIV Bathe the newborn thoroughly Administer zidovudine Assist the mother to breastfeed

Bathe the newborn thoroughly Explanation: The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.

A hepatitis B positive mother delivers a newborn. What precautions would the nurse take in caring for this infant? Select all that apply. Give the mother a one-time dose of hepatitis B immunoglobulin within 12 hours after delivery. Bathe the newborn thoroughly soon after birth to remove maternal blood. Give the newborn the HBV vaccination within 12 hours after birth. Tell the mother that she cannot breast-feed her newborn due to the infection. The newborn will need to stay in the hospital for several extra days for additional IV medications to treat the infection.

Bathe the newborn thoroughly soon after birth to remove maternal blood. Give the newborn the HBV vaccination within 12 hours after birth. Explanation: Hepatitis B positive mothers run a high risk of transmitting the disease to their newborns if the infant is not treated immediately and precautions taken. Bathing immediately after birth is one precaution. Additionally, the newborn receives the HBV vaccination along with a one-time dose of hepatitis B immunoglobulin.

A primagravida has an office appointment in her 39th week of pregnancy. Which assessment data is most definitive of the onset of labor? The mother reports frequent urination. The fetal head is engaged in the pelvis. Cervical ripening is noted on examination. Expulsion of the mucous plug.

Cervical ripening is noted on examination. Explanation: Clinical signs that labor is approaching include ripening or softening of the cervix with effacement and dilation. Frequent urination is common during engagement where the fetal head is in the pelvis. This is common up to 2 weeks before true labor begins. Expulsion of the mucous plug also is common a week or two before labor begins.

The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention? Hesitates to hold newborn, expressing disappointment with baby's appearance. Neglects to engage or provide care or show interest in infant. Tearful for several days, difficulty eating and sleeping. Express doubt in ability to care for newborn.

Neglects to engage or provide care or show interest in infant.

The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply. previous oral contraceptive use first pregnancy age 3 0 years severe varicose veins preeclampsia

previous oral contraceptive use severe varicose veins preeclampsia

At what point should the nurse expect a healthy newborn to pass meconium? before birth within 1 to 2 hours of birth by 12 to 18 hours of life within 24 hours after birth

within 24 hours after birth

If a delivering mother weighed 140 pounds at the time of delivery, how much weight should she have lost when she goes home 2 days later, based upon the average pattern? 5-10 pounds 10-15 pounds 15-22 pounds 17-29 pounds

17-29 pounds Explanation: Normal expected weight loss is approximately 12-14 pounds with the delivery of the fetus, placenta and amniotic fluid then an additional 5-15 pounds in the early postpartum period from fluid loss.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? 1 week 2 weeks 3 weeks 4 weeks.

2 weeks

A client arrives at the clinic in labor. The nurse assesses a bulging perineum and prepares for the birth. Place the nurse's actions in sequence. All options must be used. 1 Call for assistance 2 Put on gloves 3 Support perineum with one hand 4 Deliver the head 5 Palpate for a nuchal cord 6 Use bulb to suction mouth and nose

Call for assistance Put on gloves Support perineum with one hand Deliver the head Palpate for a nuchal cord Use bulb to suction mouth and nose

With which findings would the nurse anticipate a diagnosis of false labor? Regular contractions 8 minutes apart A feel of pressure in the pelvic region Cervical dilation of 1 cm Softening of the cervix

Cervical dilation of 1 cm Explanation: To be in true labor, there needs to be cervical dilation and effacement. Cervical dilation of 1 cm does not show progression in dilation as the contractions are not effective in producing further dilation. The other options could possibly be signs of true labor with cervical dilation.

A nursing instructor informs the student that which stimuli initiate respirations in the newborn? Select all that apply. hypercapnia alkalosis hypoxia acidosis elevated CO2

hypercapnia hypoxia acidosis Explanation: The first breath of life is a gasp that generates an increase in transpulmonary pressure and results in diaphragmatic descent. Hypercapnia, hypoxia, and acidosis resulting from normal labor become the stimuli for initiating respirations.

A newborn's ears are lined up below a line from the inner to outer canthus of the eye, extending past the ear. What other possible findings should the nurse be aware of in this client? Select all that apply. Cleft palate Deafness Cognitive impairment Internal organ defects Hydrocephalus

Cognitive impairment Internal organ defects Explanation: A newborn noted to have low-set ears often has associated cognitive impairments or internal organ defects. Numerous genetic disorders have low-set ears as one of the characteristics of the syndrome. Deafness, cleft palate and hydrocephalus are not associated with low-set ears.

A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply. Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. Use a bottle to feed the infant until the pain and tenderness subside. If infant refuses to feed, pump the breast to maintain flow. Until antibiotics are completed, pump the left breast and dispose of the milk.

Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow.

The nurse will be performing the Leopold's maneuver to determine the position of the fetus. List in order the steps that the nurse would take. All options must be used. 1 Determine presentation. 4 Determine attitude. 2 Determine position. 3 Confirm presentation

Determine presentation. Determine position. Confirm presentation. Determine attitude.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Help the woman to sit up in a semi-Fowler's position. Turn her or ask her to turn to her side. Administer oxygen at 3 to 4 L by nasal cannula. Ask her to pant with the next contraction.

Turn her or ask her to turn to her side. Explanation: The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

A nursing student is studying postpartal complications. Thromboembolic conditions have which risk factors? Select all that apply. anemia diabetes cigarette smoking obesity irritable bowel multiparity

anemia diabetes cigarette smoking obesity multiparity

Which nursing suggestions are options for the client experiencing intense pain in the active phase of labor? Select all that apply. Patterned breathing Hypnosis Effleurage Pain medication Massage Acupressure

Patterned breathing Hypnosis Pain medication Massage Acupressure

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? "Physiologic jaundice usually begins in the first 24 hours of after birth." "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." "Breastfed babies need supplements of glucose water to help lower bilirubin levels." "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)."

"Breastfed babies need supplements of glucose water to help lower bilirubin levels." Explanation: Physiologic jaundice (hyperbilirubinemia) is characterized by a yellowish skin, mucous membranes, and sclera that occurs within the first 3 days of life. Physiologic jaundice is caused by accelerated destruction of fetal RBCs that have a shortened life span (80 days compared with the adult 120 days). Normally the liver removes bilirubin (the by-product of RBC destruction) from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing the characteristic signs of physiologic jaundice. Expose the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin. Glucose water supplementation should be avoided since it hinders elimination.

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received? "I will feed him at least 30 cc of water daily." "I need to give him iron supplements daily." "I will give him vitamin D supplements daily for the first 2 months of life." "Since we live in a rural area, I must ensure he receives adequate fluoride supplementation."

"I will give him vitamin D supplements daily for the first 2 months of life." Explanation: As per the recommendations of AAP, all newborns should receive a daily supplement of vitamin D during the first 2 months of life to prevent rickets and vitamin D deficiency. There is no need to feed the newborn water, as breast milk contains enough water to meet the newborn's needs. Iron supplements need not be given, as the newborn is being breastfed. Infants over 6 months of age are given fluoride supplementation if they are not receiving fluoridated water.

The hospital is providing a class on newborn care to a group of parents prior to their discharge with their newborns. Which statement by a parent would indicate that further teaching is needed? "We will dress our son in the same amount of clothing that we are wearing in the house plus a light blanket." "If our baby turns red in the face and strains to have a stool that means she is constipated." "We will always keep the crib rails up when our son is in the bed." "The bulb syringe is to be used to clean out the excess secretions from our infant's nose."

"If our baby turns red in the face and strains to have a stool that means she is constipated." Explanation: Straining and turning red in the face when having a stool is not indicative of constipation. This is normal behavior. Parents should be comfortable in using a bulb syringe, remember to keep crib rails up at all times, and should not overdress their infants to try to keep them warm.

A nursing instructor teaching students how to check the client's uterus postpartum realizes that further instruction is needed when one of the students says: "One to two hours after birth the fundus is typically between the umbilicus and symphysis pubis." "One to two hours after birth the fundus is typically at the level of the umbilicus." "Six to twelve hours after birth the fundus is typically at the level of the umbilicus." "Normally the fundus progresses downward at a rate of 1 fingerbreadth per day after birth."

"One to two hours after birth the fundus is typically at the level of the umbilicus." Explanation: One to two hours after birth the fundus is typically between the umbilicus and symphysis pubis. At 6 to 12 hours after birth the fundus usually is at the level of the umbilicus. Normally the fundus progresses downward at at rate of one fingerbreadth per day after birth.

A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client? "The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." "It is normal for the discharge to be deep red since it consists of leukocytes, decidual tissue, RBCs, and serous fluid." "The discharge at this point in the postpartum period consists of RBCs and leukocytes." "This discharge is called lochia, and it consists of leukocytes and decidual tissue."

"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color."

A nurse is making a home visit to a new mother with a 5-day-old newborn. The mother tells the nurse that the baby is fussy and she does not know how to calm her. Which suggestions would be most appropriate for the nurse to make? Select all that apply. "Try swaddling her nice and snuggly." "Have her lie on your lap on her back." "Gently tap her shoulders and back." "Try shushing her loudly." "Encourage her to suck."

"Try swaddling her nice and snuggly." "Try shushing her loudly." "Encourage her to suck." Explanation: Recent research outlines five things (the five "S") that parents can do to calm a fussy infant: swaddling tightly; using the side/stomach position on the lap of the caretaker; shushing loudly or continuous white noise; swinging using any rhythmic movement; and sucking (Karp, 2014).

The mother calls the nurse to check her baby after noting the right side of the body is dark red while the left side of the baby is pale. Which question to the mother should the nurse prioritize when assessing the situation? "How long has it been since you last breast-fed?" "Was the baby recently crying?" "Was the baby sleeping on their back?" "Did you hold the baby while they were sleeping?"

"Was the baby recently crying?" Explanation: This is termed Harlequin sign and is related to dilatation of blood vessels often following vigorous crying. This can also happen if the baby is sleeping on its side instead of its back. The condition will resolve without intervention. This is not caused by breast-feeding or holding the baby while the infant is sleeping.

When teaching possible differences in labor between the first labor experience and all other labors, which statement is most beneficial to assist a woman's psyche? "The labor process is typically shorter for subsequent pregnancies." "You can have input into the labor plan as you know what to expect." "The intensity of contractions are much greater throughout the labor." "You had a successful labor and vaginal delivery with your first pregnancy."

"You had a successful labor and vaginal delivery with your first pregnancy." Explanation: Reminding the client of her successful labor and birth best provides confidence, which strengthens a woman's psyche. It is true that subsequent pregnancies are typically shorter in length, and input in the labor plan by the multipara client can be expressed (since the woman has already experienced the process), but these are not as important as successfully completing the process. Depending upon the client's past experiences, the intensity of the contractions may or may not be more intense.

The nurse is assisting the health care provider with the pelvic assessment of a pregnant client. The nurse concludes that the obstetric conjugate will be how long if the distance between the symphysis pubis and sacral promontary is 13 cm? 15 cm 11 cm 9 cm 13 cm

11 cm Explanation: The obstetric conjugate measurement is the smallest diameter of the inlet through which the fetus must pass. This cannot be measured directly. This is determined by subtracting 1.5 cm to 2 cm from the diagonal conjugate, which extends from the symphysis pubis to the sacral promontary.

The young mother is nervous about discharge with her first child. The nurse encourages the mother by pointing out various instructions, including to call her health care provider if the newborn does not void within which time period? 6 hours 12 hours 18 hours 24 hours

12 hours

A nurse is making a home visit to a new mother who gave birth vaginally five days ago. The woman tells the nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. The woman asks what the average weight loss at 5 days into the postpartal period is. Which information would the nurse incorporate into the response? 19 lb 9 lb 14 lb 24 lb

19 lb Explanation: The rapid diuresis and diaphoresis during the second to fifth days after birth usually result in a weight loss of 5 lb (2 to 4 kg), in addition to the approximately 12 lb (5.8 kg) lost at birth. Lochia flow causes an additional 2- to 3-lb (1-kg) loss, for a total weight loss of about 19 lb.

The LPN is preparing to assist the RN with the initial admissions assessment of the newborn. The nurse should explain to the new mother that this will be completed in what time frame after birth? 30 minutes 1 hour 2 hours 4 hours

2 hours Explanation: The infant and mother need time for bonding after delivery. While the nurse is monitoring and may take vital signs, the initial full exam must be completed within 2 hours of birth. The options of 30 minutes or 1 hour are options which would be based on the individual situation. Waiting for 4 hours is too long and may result in danger signs of potential complications being missed.

In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman's behavior to be characterized as which of the following? Gaining self-confidence Adjusting to her new relationships Being passive and dependent Resuming control over her life

2. The correct response is C. According to Reva Rubin, the mother is very passive and is dependent on others to care for her for the first 24 to 48 hours after giving birth. Gaining self-confidence would characterize a mother in the taking-hold phase, during which the mother demonstrates mastery over her own body's functioning and feels more confident in caring for her newborn. Adjustment to relationships does not occur until the third phase, letting go, when the mother begins to separate from the symbiotic relationship she and her newborn enjoyed during pregnancy and birth. Resuming control over her life would denote the second phase of taking hold, during which the mother does resume control over her life and gains self-confidence in her newborn care.

When managing a client's pain during labor, nurses should: Make sure the agents given do not prolong labor Know that all pain relief measures are similar Support the client's decisions and requests Not recommend nonpharmacologic methods

3. The correct response is C. The entire focus of the labor and birth experience is for the family to make decisions, not the caretakers. The nurse's role is to respect and support those decisions. Decisions about pain management are not based on length of the various stages of labor, but rather on what provides effective pain relief for the laboring woman. Pain relief measures differ. Each individual responds differently and uniquely to various pain relief measures. Not recommending nonpharmacologic measures demonstrates bias on the nurse's part; it is not the nurse's decision to make, but rather the client's.

Which finding would the nurse describe as "light" or "small" lochia? 1- to 2-inch lochia stain on the perineal pad or a 10 ml loss 4-inch stain or a 10 to 25 ml loss 4- to 6-inch stain with an estimated loss of 25 to 50 ml pad is saturated within 1 hour after changing it

4-inch stain or a 10 to 25 ml loss Explanation: Typically the amount of lochia is described as follows: scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; light or small: 4-inch stain or a 10 to 25 ml loss; moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; large or heavy: a pad is saturated within 1 hour after changing it.

The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? Reposition the client on the left side. Begin 100% oxygen via face mask. Document this as indicating a normal pattern. Call the health care provider immediately.

5. The correct response is C. Fetal accelerations denote an intact central nervous system and appropriate oxygenation levels demonstrated by an increase in heart rate associated with fetal movement. Accelerations are a reassuring pattern, so no intervention is needed. Turning the woman on her left side would be an appropriate intervention for a late deceleration pattern. Administering 100% oxygen via face mask would be appropriate for a late or variable deceleration pattern. Since fetal accelerations are a reassuring pattern, no orders are needed from the health care provider, nor does the health care provider need to be notified of this reassuring pattern.

A nurse is explaining to new parents how a newborn adapts to extrauterine life. When discussing the physiologic changes that occur, the nurse would explain that this transition usually takes the first: 6 to 10 hours of life. 4 to 6 hours of life. 8 to 12 hours of life. 2 to 4 hours of life.

6 to 10 hours of life. Explanation: The infant must make many changes to survive outside the uterus. Immediately after birth, respiratory gas exchange, along with circulatory modifications must occur. During this time, the infant also experiences complex changes in major organ systems. The transition usually takes place within the first 6 to 10 hours of life; however, some adaptations take weeks to attain full maturity.

In a local health care facility, a newborn is admitted to the transition nursery for close observation following birth, and to provide attachment time with his parents since his mother is febrile and hypertensive. Assessments will be conducted for what period of time after admission to the nursery? 2 to 4 hours 4 to 8 hours 6 to 12 hours 12 to 24 hours

6 to 12 hours Explanation: The stabilization and transition time for a newborn is 6 to 12 hours when the nurse will closely observe the newborn, monitoring its blood sugar, heart rate, respiratory status and temperature and complete a full physical exam.

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: 5. 6. 7. 8.

7. Explanation: The newborn would receive an Apgar score of 7: 1 point for heart rate (<100 beats/minute), 2 points for respiratory rate (regular respirations at a rate between 30 and 60 breaths/minute), 2 points for muscle tone (tight flexion), 1 point for reflex irritability (grimace), and 1 point for skin color (acrocyanosis).

The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters? 0 to 2 5 to 7 3 to 4 8 to 10

8 to 10 Explanation: The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.

Interventions that are underutilized in promoting a normal birth. Select all that apply. Oral nutrition and fluids in labor Open glottis pushing in the second stage of labor Skin-to-skin contact after birth for infant bonding Routine artificial rupture of membranes (amniotomy) Labor induction with Pitocin given intravenously Routine episiotomy to shorten labor length

8. The correct responses would include "A," "B,"and "C" since all of these are evidence-based interventions that are physiologically sound without placing the mother or the neonate in any danger. Food and clear fluids provide hydration and nutrition and give comfort to laboring women. Fasting during labor will increase gastric acid production. Open glottis while pushing allows the woman's body to sense the urge to push naturally. Skin-to-skin contact promotes mother-infant bonding and warmth. Incorrect responses would include "D," "E," and "F" since these are artificial means to speed up the labor process which places the mother and newborn in jeopardy. Amniotomy may be associated with umbilical cord prolapse and fetal heart rate decelerations. Episiotomy is associated with an increase in third- and fourth-degree perineal lacerations, discomfort, and healing delays. Induction with Pitocin may cause tetanic contractions causing hypoxia to the fetus.

The nursing instructor is conducting a class exploring the various changes which occur in the early postpartum period. The instructor determines the session is successful when the students correctly point out which definition of bonding? A process of developing an attachment and becoming acquainted with each other The skin-to-skin contact that occurs in the birth room An ongoing process in the year after birth Family growing closer together after the birth of a new baby

A process of developing an attachment and becoming acquainted with each other Explanation: Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a yearlong process, and the family growing closer together after the birth of a new baby is not bonding.

The health care provider and nurse are assisting the client in the delivery of the fetus. The mother has been pushing with little effect. As the nurse obtains the instruments to assist with delivery, which method is used for pain relief? IV pain medication A pudendal block General anesthesia An epidural

A pudendal block Explanation: A pudendal block is given just before the baby is born to provide pain relief for birth. Given at this time, the pudendal block does not impact the client's ability to push (which can prolong the labor). This block is also effective for births that require instruments to deliver the baby or complete an episiotomy. Though IV pain medication is rapid acting, it is not the analgesia of choice at this time. General anesthesia is used in emergency situations when the baby has to be delivered quickly. An epidural is for pain relief through the labor process.

Which factor would demonstrate physiologic respiratory adaptation to extrauterine life in a newborn infant? Taking a breath within 3 minutes of delivery with stimulation Abrupt temperature change upon delivery, causing a cry Increase in oxygen levels and decrease in CO2 levels, stimulating respirations Rapid respirations following a cesarean birth to eliminate fetal fluids

Abrupt temperature change upon delivery, causing a cry Explanation: Respiratory adaptation following birth is seen in an infant that responds with a strong cry following thermal changes, such as those the newborn experiences going from the warm uterus to the cold outside air. The first breath should occur within the first few moments after birth, not after 3 minutes. The rapid decrease in oxygen and increase in the CO2 levels, not the reverse, serves as stimulation for respirations. Tachypnea following a cesarean birth does not demonstrate respiratory adaptation but may indicate fluid retention and complications.

The nurse in a women's center is assisting the health care provider in obtaining the measurement of a pregnant client's pelvis. Which measurements are suggestive of the ability to have a vaginal delivery? Select all that apply. An obstetric conjugate of 12 cm. A diagonal conjugate of 32 cm. A pubic arch angle of 90 degrees A pelvic angle of 25 degrees Minimal ischial spine protrusion into the midpelvis

An obstetric conjugate of 12 cm. A pubic arch angle of 90 degrees Minimal ischial spine protrusion into the midpelvis

The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. What interventions would be inappropriate for this client? Apply petroleum gauze to the penis with each diaper change. Monitor the amount of bleeding and chart it. Position the infant on his side for comfort. Administer analgesics for pain on a scheduled basis.

Apply petroleum gauze to the penis with each diaper change. Explanation: When a newborn is circumcised using a Plastibell, petroleum gauze is not used since the Plastibell protects the glans of the penis until it is healed. All other interventions are appropriate.

At which point along the birth canal must the fetal head extend for successful passage? At the level of the iliac crest At the level of the symphysis pubis At the level of the ischial spines At the level of the pelvic inlet

At the level of the symphysis pubis Explanation: Fetal extension occurs late in the labor process as the fetus extends through the final portion of the passageway. The fetal head must extend at the symphysis pubis for successful passage. The next step is the head being born. The pelvic inlet, iliac crest and ischial spines are high in the birth canal.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Limit the bathing time to 5 minutes. Bathe the baby in water between 90 and 93 degrees. Bathe the baby under a radiant warmer. Postpone breastfeeding until after the initial bath.

Bathe the baby under a radiant warmer.

The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply. Breasts feel slightly firm. Nipples have several cracks on both breasts. One reddened area on the left breast 3 cm in size. Flattened nipple on the right breast Breasts are non-painful

Breasts feel slightly firm. Flattened nipple on the right breast Breasts are non-painful Explanation: Normal findings for a breast exam in a Day 2 postpartum mother should include non-painful breasts, slight engorgement indicative of the milk coming in, and nipples that are either erect or can be drawn out. Reddened areas and cracked nipples are abnormal findings.

The parents are concerned their newborn appears to be cold all the time. The nurse should point out the infant is best helped by which primary method in the first few days? External with blankets by the nursing staff Skin to skin contact with mother Brown fat store usage Shivering and increased metabolic rate

Brown fat store usage Explanation: Brown fat stores are used by the newborn infant to maintain warmth until feeding begins and the infant is able to maintain temperature without assistance. The infant's thermoregulatory system is not fully functional at birth. Infants cannot shiver to warm themselves. The use of external blankets as well as skin to skin contact with the mother assists in keeping the baby's temperature within the normal range, but they are not the primary mechanism for temperature regulation in the newborn infant.

A client in her third trimester of pregnancy arrives at a health care facility with a report of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the nurse indicates that the client has edema of the lower extremities, along with an increase in vaginal discharge. What should the nurse do next? Notify the health care provider. Continue to monitor the client. Assess the client's blood pressure. Prepare the client for birth.

Continue to monitor the client. Explanation: The nurse knows that the client is experiencing lightening. Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis and may occur 2 weeks or more before labor. The uterus lowers and moves into a more anterior position. The client may report increased respiratory capacity, decreased dyspnea, increased pelvic pressure, cramping, and low back pain. She may also note edema of the lower extremities as a result of the increased stasis of blood pooling, an increase in vaginal discharge, and more frequent urination. The nurse would continue to monitor the client as this is a normal progression of pregnancy.

A newborn is placed in an open crib in the newborn nursery, which is located near the doorway to the hall. What type of heat loss would this infant experience? Conductive Evaporative Convective Radiant

Convective

A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply. Determine the mother's room temperature during the visit. Ask the mother if she fed the newborn while the infant was in the room with her. Turn the nursery temperature up to 80°F (26.7°C). Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door.

Determine the mother's room temperature during the visit. Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door.

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 97.7oF (36.5oC), and blood pressure 78/40 mm Hg. Which action should the nurse prioritize? Report tachypnea. Recheck blood pressure in 15 minutes. Put warming blanket over infant. Document normal findings.

Document normal findings. Explanation: These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 98.6&%176;F (36.5°C to 37°C). Blood pressure should be 60 to 80/40 to 45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.

The nurse is caring for a client with severe anxiety. The client states, "I have never had a baby before and am scared to death that I will not be able to do it." Which suggestion is most helpful? Encourage the use of a doula. Identify strategies to decrease anxiety. Document history on prenatal communication sheet. Consider requesting an anxiolytic during labor.

Encourage the use of a doula. Explanation: A client with severe anxiety and statements of self-doubt would greatly benefit by having a trained obstetric professional coach her through the labor process. Identifying strategies and documenting the information on a communication sheet is appropriate but not as helpful. The health care provider would discuss prescription medication.

A postpartum mother calls the nurse in and tells her that her right calf hurts whenever she walks around the room or in the hall. What other data needs to be collected in assessing this patient for a DVT? Select all that apply. Feel the right calf for increased warmth. Note any reddened areas on the right calf. Note capillary refill of the toes. Measure the diameter of both calves. Have the mother actively flex both legs for equal movement.

Feel the right calf for increased warmth. Note any reddened areas on the right calf. Measure the diameter of both calves. Explanation: A deep vein thrombus (DVT) is suspected in a client who is complaining of pain in her calves and, upon inspection, there is redness of the calf, increased size, and increased warmth. It is not advised to have the client actively flexing her legs due to the risk of dislodging the clot. Checking capillary refill will provide no more information related to a DVT.

In which manner is the fetal status best assessed during the active and transition stage of labor? Fetal heart rate at the peak of a contraction Fetal movement on the tocometer Fetal heart rate between contractions Fetal kicks over a one minute period

Fetal heart rate at the peak of a contraction Explanation: Normal labor stresses the fetus by increasing intracranial pressure, decreasing heart rate and placental blood flow. Assessing the fetal heart rate during the peak of the contraction best communicates how the fetus is tolerating the labor. Fetal movement and fetal kicks can indicate that a fetus is compromised but that is a late sign of distress.

Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? Select all that apply. Fingernails are present and extend to the end of the fingers. Pinnae are flexible with rapid recoil. Labia minora are prominent upon observation. The newborn has a relaxed posture. Creases on the feet cover 2/3 of the bottom of the feet.

Fingernails are present and extend to the end of the fingers. Pinnae are flexible with rapid recoil. Creases on the feet cover 2/3 of the bottom of the feet. Explanation: Full-term infants will have fingernails, a pinna with cartilage with rapid recoil when bent down, and creases over the upper 2/3 of the sole of the foot. The labia majora will be more prominent in full-term infants and their posture is flexed.

The nurse is escorting the newborn to the transition nursery for the initial assessment and care. The nurse is prepared to carefully monitor the infant during the transition period, which occurs at which time interval? First 12 to 24 hours First 6 to 12 hours First 1 to 6 hours First 1 to 12 hours

First 6 to 12 hours Explanation: The first 6 to 12 hours after birth are the critical transition hours for a newborn. The newborn may stay with the mother, but under close observation by a nurse. The newborn requires close monitoring throughout the entire period but the first 6 to 12 hours are the time when more complications may present and must be handled early to prevent long-term complications.

Parents are taking home their second child. They also hve a 2-year-old at home. The nurse would anticipate which behavior by these parents? Confidence since they have another child already No questions of the nurse Only questions specific to breast-feeding General questions about different aspects of newborn care

General questions about different aspects of newborn care Explanation: Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn.

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 gm/dL and hematocrit of 42%. Which result should the nurse prioritize? Hemoglobin 13 gm/dL and hematocrit 40 percent in a woman who has given birth vaginally Hemoglobin 12 gm/dL and hematocrit 38 percent in a woman who has given birth vaginally Hemoglobin 11 gm/dL and hematocrit 34 percent in a woman who has given birth by cesarean Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean

Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean Explanation: First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 mL of blood lost during the delivery process, the hemoglobin should decrease by 1 gm/dL and the hematocrit by 2 percent. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 mL to 500 mL and for a cesarean delivery approximately 500 mL to 1000 mL. The loss of hemoglobin from 14 gm/dL to 9 gm/dL is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 mL of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.

The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse? Spinal column movement Shoulder movement Clavicles for dislocation Hip for dislocation

Hip for dislocation Explanation: Ortolani maneuver is used to assess the possibility of a dislocated hip in an infant. Ortolani maneuver does not assess for spinal column movement, shoulder movement, nor does it assess the clavicles for dislocation. There is no specific movement to assess for spinal column movement, shoulder movement, or clavicle dislocation.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue? Hold the baby frequently. Speak to his friends who have children. Read up on parental care. Have the client speak to the primary care provider on her husband's behalf

Hold the baby frequently. Explanation: The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.

The nurse is conducting an assessment on a newborn male and the parents question why the nurse is using a penlight to examine the scrotal sac. The nurse should point out this helps to eliminate which potential disorder? Cryptorchidism Hydrocele Epispadias Phimosis

Hydrocele Explanation: Hydrocele occurs when there is a buildup of fluid in the scrotal sac and should be noted on assessment. If there is fluid in the scrotal sac, it will be translucent when the penlight is placed against it. If there isn't fluid, the sac will remain dark. Cryptorchidism results when the testes do not descend into the scrotal sac during fetal life. These are checked by putting slight pressure on the scrotal sac to feel the testes. The urinary meatus should be positioned at the tip of the penis. If the opening is located abnormally on the dorsal (upper) surface of the glans penis, the condition is called epispadias. Phimosis, or tightly adherent foreskin, is a normal condition in the term newborn.

The infant born at 5 a.m. has moved to the transition phase and is progressing well. The nurse documents a HR 130, RR 42, axillary temperature 99.5oF (37.5oC), and blood pressure 60/40 at 6:45 a.m. When should the nurse plan to reassess the infant's vital signs? In 15 minutes In 30 minutes In 45 minutes In 60 minutes

In 30 minutes Explanation: The nurse needs to assess the vital signs every half hour for the first 2 hours of life for a healthy infant. Some serious complications may require vital sign checks at sooner intervals. After the first two hours have passed, the vital signs should be checked as per the institution policies.

Which symptoms indicate that the client has begun the transition phase of labor? Select all that apply. Increase in bloody show The woman is more quiet and introverted The client states an urge to push Irritability and restlessness may occur The client may begin to cry Hyperventilation may occur

Increase in bloody show The client states an urge to push Irritability and restlessness may occur The client may begin to cry Hyperventilation may occur

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply. Initiate early and frequent breast-feeding. Dry the newborn off immediately after birth to prevent chilling. Feed the newborn formula every 4 hours, starting 8 hours after birth. Feed only glucose water for the first 24 hours following birth. Begin kangaroo care for the newborn.

Initiate early and frequent breast-feeding. Dry the newborn off immediately after birth to prevent chilling. Begin kangaroo care for the newborn.

The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply. Inspect the episiotomy for sutures and to ensure that the edges are approximated. Palpate the episiotomy for pain. Note any hemorrhoids. Place the patient in Trendelenburg position for inspection. Gently palpate for any hematomas.

Inspect the episiotomy for sutures and to ensure that the edges are approximated. Note any hemorrhoids. Gently palpate for any hematomas. Explanation: The client is placed in the Sims position, not Trendelenburg position, for inspection. The nurse will then use a light to look at the perineum, noting any hemorrhoids, inspecting the episiotomy (if present) and palpating for any hematomas. The episiotomy is not palpated due to the pain associated with it, and the nurse can visually inspect it.

The nurse suspects that a newborn is experiencing a drop in its blood sugar. Which symptoms are early signs of hypoglycemia in this client? Select all that apply. Jitteriness Diaphoresis Low body temperature Increased appetite Irritability

Jitteriness Low body temperature Irritability

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply. Lanugo on the back Vernix caseosa over the abdomen and lower extremities Milia Acrocyanosis Jaundice

Lanugo on the back Milia Acrocyanosis Explanation: A full-term newborn may have thin patches of lanugo over his back, shoulders or arms. He may also have milia, which appear as white papules on the face. Acrocyanosis at 3 hours of age is also a normal finding. However, this should resolve by 24 to 48 hours of age. A newborn at 3 hours of age should never have jaundice. Vernix on the abdomen and lower extremities is seen in preterm infants, not full-term ones.

What should the nurse consider when checking results of blood work done on a newborn? Site of the blood sample does not make a difference. Leukocytosis is usually present. The newborn's platelet count is higher than an adult's. The newborn's aggregation ability is lower than an adult's.

Leukocytosis is usually present. Explanation: The site of the blood sample matters. For instance, capillary blood has higher levels of HGB and HCT compared to venous blood. Leukocytosis (elevated white blood cells) is present as a result of birth trauma soon after birth. The newborn's platelet and aggregation ability are the same as adults.

The nurse is admitting a newly delivered mother to her floor. What medical and pregnancy history would the labor and delivery nurse include in the report? Length of labor Maternal blood type The newborn's weight Apgar scores

Maternal blood type Explanation: Medical and pregnancy history would include information pertinent to the mother, which would be the mother's blood type, Rh and rubella status. History of the length of labor are part of the labor and birthing history. The infant's Apgar scores and birth weight are part of the newborn history.

A nurse is performing a detailed assessment of a female newborn. Which observations indicate normal findings? Select all that apply. Mongolian spots enlarged fontanelles swollen genitals low-set ears short, creased neck

Mongolian spots swollen genitals short, creased neck

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply. Nasal flaring Respiratory rate of 64 breaths per minute Bluish coloration of hands and feet Chest retractions Heart rate of 120 beats per minute

Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions Explanation: Signs of respiratory distress in the newborn include tachypnea (respirations greater than 60 breaths/min), tachycardia (heart rate greater than 160/beats/min), nasal flaring, chest retractions, and generalized cyanosis. Blue hands and feet, referred to as acrocyanosis, is caused by poor peripheral circulation not respiratory distress.

The nurse has obtained the vital signs of a postpartum client 24 hours after delivery and records: 99.0oF, RR 18, HR 78, and BP 140/90 mm Hg. Which action should the nurse prioritize? Notify the RN of the slight elevation in BP. Nothing; the vital signs are within normal limits. Recheck all vital signs in 30 minutes. Recheck only the BP in 30 minutes.

Notify the RN of the slight elevation in BP. Explanation: The LPN should prioritize notifying the RN immediately for further assessment of this client. An elevated BP may be a sign the patient is developing preeclampsia after delivery. The other vital signs are within normal limits. Further assessment of the vital signs should be conducted depending on the client's situation.

What physical change does not contribute to the impetus for a full-term newborn to begin breathing following birth? The infant experiences a drastic decrease in his oxygen level after the cord is cut. The respiratory center in the brain is stimulated by the noise around the newborn. The environment surrounding the newborn is colder than in utero. The newborn is touched for the first time by human hands.

Once the umbilical cord of a newborn is cut, there is a chemical change that stimulates the respiratory center of the brain caused by a decrease in oxygen and a rise in carbon dioxide levels. The respiratory center is not stimulated by noise surrounding the newborn. A change in environmental temperature and being touched directly for the first time also serve as stimulants for breath.

A postpartum woman is concerned about constipation following delivery. What factor(s) contribute to this problem? Poor diet after delivery Perineal pain Hemorrhoidal discomfort Iron supplements Too much fluids

Perineal pain Hemorrhoidal discomfort Iron supplements Explanation: After delivery, many women experience a great deal of perineal pain, as well as hemorrhoidal pain, which leads to constipation because the woman is reluctant to defecate, fearing pain. Additionally, iron supplements contribute to constipation also.

A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take? Feed the newborn to provide more glucose. Place the newborn away from drafts and under a blanket. Begin the newborn on oxygen with BNC at 2L. Place a pillow under the newborn to raise the head of the bed.

Place the newborn away from drafts and under a blanket. Explanation: When a newborn becomes cold stressed, they often develop respiratory distress. The newborn's temperature is low, so the first nursing action is to place the newborn in a warmer environment and cover with a blanket to warm the newborn up. The serum glucose is normal so the newborn does not need additional nutrition. The newborn does not have documented hypoxia, so oxygen is not appropriate. Pillows are never used in newborn's beds due to the risk of suffocation.

When the nurse performs the Ortolani maneuver, which action would be appropriate? Select all that apply. Listen for click when the legs are abducted. Place the newborn in a supine position. Position the newborn prone with the head face down Attempt to abduct the hips 180 degrees while applying upward pressure. Attempt to abduct the hips 90 degrees while applying upward pressure.

Place the newborn in a supine position. Attempt to abduct the hips 180 degrees while applying upward pressure. Explanation: The newborn should be in the supine position. The nurse will flex the hips and knees to 90 degrees at the hip, then will attempt to abduct the hips 180 degrees while applying upward pressure. A "click" or a "cluck" should not be heard when the legs are abducted.

The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step? Position the newborn on side, and suction with a bulb syringe. Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. Position the newborn on side with head slightly below body; use a small suction catheter to clear nose. Position the newborn on side with head slightly below body; use a bulb syringe to clear nose.

Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. Explanation: The infant needs to have bulb suction used to remove the secretions from the mouth first; the head should be held slightly lower than the body to facilitate use of gravity. A bulb syringe, not a small suction catheter, is used to suction the mouth and nose of a newborn. The mouth should be cleared first to prevent possible aspiration of secretions. Suctioning the nose first could cause the infant to inhale the secretions in the mouth if it is suctioned first.

The nurse is teaching a couple about the pros and cons of circumcision for their infant son. The nurse knows teaching has been effective when the couple can identify which contraindications to circumcision? Select all that apply. Difficult intravenous access Preterm infant Bleeding disorder Congenital genitourinary disorder Active infection

Preterm infant Bleeding disorder Congenital genitourinary disorder Active infection Explanation: The procedure is contraindicated in neonates who 1) are still in the transition period; 2) are sick or preterm; 3) have a family history of bleeding disorder until the disorder is ruled out in the neonate; 4) have received a diagnosis of a bleeding disorder; 5) have a congenital genitourinary disorder, such as epispadias or hypospadias. The procedure does not necessitate IV access.

The nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the newborn? Maintain oxygen saturation at 95% or above. Accompany the newborn to all radiologic examinations. Prevent pain as much as possible. Teach the parents to take pulse and blood pressure measurements.

Prevent pain as much as possible. Explanation: Providing comfort measures to the newborn who will be subjected to a variety of painful procedures is the highest priority. Be vigilant in ensuring the newborn's comfort, since it cannot report or describe pain. Experiencing pain will cause stress in the infant and increase the workload on the heart. Assist in preventing pain as much as possible; interpret the newborn's cues suggesting pain and manage it appropriately. Maintaining a set saturation may not be a possibility dependent upon the heart defect the infant has.

A nurse is doing an admission assessment on a female newborn. Which findings would warrant notification of the physician? Select all that apply. Heart rate of 150 Scaphoid abdomen Episodic breathing Head circumference of 38 cm Overlapping cranial sutures

Scaphoid abdomen Head circumference of 38 cm Explanation: A heart rate from 100 to 160 is considered a normal range for a newborn. The newborn will also exhibit an episodic breathing pattern, where the respirations are irregular with small pauses interspersed with rapid respirations. Overlapping cranial sutures are also normal, especially as this is the mother's first baby. The two abnormal findings are the scaphoid abdomen, which should be rounded or protuberant, and the head circumference (HC) of 38 cm. A normal HC is 33 to 35.5 cm.

The primigravida client is surprised by the continued uterine contractions while holding her new baby. Which explanation by the nurse will best explain these contractions? Returns the uterus to normal size Seals off the blood vessels at the site of the placenta Stops the flow of blood Closes the cervix

Seals off the blood vessels at the site of the placenta Explanation: The contractions of the uterus help to constrict the vessels where the placenta was located. This does decrease the flow of blood but is secondary in occurrence to the constriction of the blood vessels. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. Uterine involution assists in closing the cervix. Again, the other options are secondary to the constriction of blood vessels at the placental site.

The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize? Past obstetrical history Fetal status Signs that birth is imminent Client's temperature

Signs that birth is imminent Explanation: The priority is to establish the imminence of the birth, then the fetal status. The obstetrical history can wait until after the birth of the baby, if necessary. The maternal blood pressure is a higher priority over the temperature to rule out possible preeclampsia.

A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply. Take warm-to-hot showers to encourage milk release. Feed the newborn in the sitting position only. Express some milk manually before breastfeeding. Massage the breasts from the nipple toward the axillary area. Apply warm compresses to the breasts prior to nursing.

Take warm-to-hot showers to encourage milk release. Express some milk manually before breastfeeding. Apply warm compresses to the breasts prior to nursing.

A heel stick blood glucose on a 6-hour-old newborn is 44 but the venous blood sample shows a glucose of 89. What could cause this discrepancy? The bedside glucometer is not calibrated for newborns. The serum blood sugar is falsely high. There was too much blood in the heel stick test strip. The newborn is stressed and is breaking down glycogen quickly.

The bedside glucometer is not calibrated for newborns.

The nurse notes in a newborn's chart that the newborn has been diagnosed with physiologic jaundice. The nurse recognizes that physiologic jaundice is determined by what criteria? The jaundice occurred within the first 24 hours after birth. The bilirubin peaked between days 3 and 5 after birth. The bilirubin level rose 6 mg/dL to 13 mg/dL over the last 24 hours. The conjugated bilirubin is higher than the unconjugated bilirubin.

The bilirubin peaked between days 3 and 5 after birth. Explanation: Physiologic jaundice involves the liver's inability to break down the bilirubin as fast as it is being produced due to the immaturity of the liver. The criteria for physiologic jaundice is that the jaundice occurs after 24 hours of age, it peaks between days 3 and 5 and does not rise more than 5 mg dL/day. Conjugated bilirubin is the water-soluble version of bilirubin and is excreted in feces; it should always be lower than the unconjugated bilirubin.

During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? Moderate amount of dark red lochia drainage on peripad Uterine fundus palpated to the right of the umbilicus An oral temperature reading of 100.6°F Perineal area bruised and edematous beneath her ice pack

The correct response is B. A full bladder causes displacement of the uterus above it, and increased bleeding results secondary to the uncontracted status of the uterus. Massaging the uterus will help to make it firm but will not help to bring it back into the midline, since the full bladder is occupying the space the uterus would normally assume. Notifying the primary health care provider is not necessary unless the woman continues to have difficulty voiding and the uterus remains displaced. The normal location of the uterus in the fourth stage of labor is in the midline. Displacement suggests a full bladder, which is not considered a normal finding.

When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: Initial period of reactivity Second period of reactivity Decreased responsiveness period Sleep period for newborns

The correct response is B. The behaviors demonstrated by the newborn, such as alertness, stabilized heart and respiratory rates, and passage of meconium are associated with the second period of reactivity. The first period of reactivity starts with a period of quiet alertness followed by an active alertness with frequent bursts of movement and crying. During the decreased responsiveness period, also called the sleep period, the newborn is relatively unresponsive and difficult to waken.

When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? Hold your breath and push through entire contraction. Use chest-breathing with the contraction. Pant and blow during each contraction. Wait until you feel the urge to push

The correct response is D, since nondirected pushing, based on current research, leads to better outcomes for both mother and infant. Holding breath and pushing throughout the entire contraction reduce blood flow and oxygenation to the fetus. Chest breathing is not effective since it doesn't increase abdominal pressure to assist the uterus to contract. Panting and blowing are used to abstain from pushing, which is not what is needed to expel the fetus.

A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply. The penis is small. There is a family history of hemophilia. The newborn was febrile at birth but temperature is now normal. The father is uncircumcised. The infant is at 33 weeks' gestation.

There is a family history of hemophilia. The infant is at 33 weeks' gestation. Explanation: Circumcision is contraindicated for several reasons including prematurity, family history of a bleeding disorder, and illness. A fever at birth is not a problem as long as it comes back down to normal shortly after birth. A small penis or a father who was never circumcised are not reasons to delay circumcision.

The nurse is examining a newborn and notes that there is swelling on the newborn's head, limited to the right side of the head. How should the nurse interpret this finding? This is concerning since the swelling does not cross the suture lines. This is a cephalohematoma and will spontaneously resolve without interventions. This newborn is at higher risk of polycythemia due to the collected blood under the scalp. The newborn has a caput succedaneum that will go away within the first week of life.

This is a cephalohematoma and will spontaneously resolve without interventions. Explanation: The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the cephalohematoma crosses the suture lines, a skull fracture is suspected. The newborn is at higher risk of jaundice and anemia, not polycythemia. This is not a caput since there is blood accumulation under the periosteum and not tissue swelling.

During which phase of labor would the nurse anticipate providing the most emotional support for the mother? Active phase of labor Final phase of labor Transition phase of labor Latent phase of labor

Transition phase of labor Explanation: The transition phase of labor is the most difficult. This phase of the first stage of labor starts when the cervix is dilated at 8 cm and ends with full cervical dilation. The contractions at this point are strong and lasting 60 to 90 seconds. It is important that the nurse helps the woman through this stage and encourages her to rest between contractions.

During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor? A teenager who is an honor student at school A clean cut male between the age of 20 and 40 A female in her mid-20s who appears pregnant A middle-age woman who lives in another town

Typical abductors are women age 12 to 50 who appear pregnant or are overweight. They are usually married or cohabiting with a companion. They are also usually familiar with the area or live there. Often they will dress as health care personnel such as a nurse or nursing assistant. Men are not typically abductors nor are honor students.

A client who has given birth a week ago reports discomfort when defecating and ambulating. The birth involved an episiotomy. Which suggestions should the nurse provide to the client to provide local comfort? Select all that apply. Maintain correct posture. Use of warm sitz baths. Use of anesthetic sprays. Use of witch hazel pads. Use good body mechanics.

Use of warm sitz baths. Use of anesthetic sprays. Use of witch hazel pads.

The parents of a 1-day-old newborn are concerned the infant is cold and shivering. Which action should the nurse prioritize to best prevent heat loss? Keep the newborn under the radiant heater when not with mom. Cover the newborn with several blankets while under the warmer. Warm all surfaces and objects that come in contact with the newborn. Bathe and wash the newborn when temperature is 97.5° F (36.4° C)

Warm all surfaces and objects that come in contact with the newborn. Explanation: The 1-day-old infant will have regulated body temperature at this point in life and the radiant heater is no longer used. Interventions are the best way to prevent heat loss for this newborn; these would include making sure surfaces such as scales, examination tables and instruments are warm. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia, which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? Bathe the infant immediately after birth. Place the infant on the mother's abdomen after birth. Wrap the infant in a warm, dry blanket. Turn the temperature up in the birth room.

Wrap the infant in a warm, dry blanket. Explanation: Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? "Followup with your healthcare provider within 3 weeks of being discharged." Notify the healthcare provider if your temperature is greater than 99° F (37.2° C)." "You should be seen by your healthcare provider if you have blurred vision." "Call your healthcare provider if you saturate a peri-pad in less than 4 hours."

You should be seen by your healthcare provider if you have blurred vision.

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct? You should be able to resume normal activities after 2 weeks. You should not lift anything heavier than your infant in its carrier. Only clean half of the house per day to allow yourself more rest. You need to hire a maid for the first month after delivery to help out around the house.

You should not lift anything heavier than your infant in its carrier. Explanation: New mothers need their rest. They should focus on caring for their newborn and themselves. Nurses should suggest that the mother not overexert herself and limit any heavy lifting. However, mild exercise can be resumed within 1 week after delivery if approved by the physician. Performing postpartum exercises to strengthen muscle groups and walking are good exercises to begin with.

A nurse is assessing a newborn's gestational age, When determining neuromuscular maturity, which parameters would the nurse assess? Select all that apply. lanugo genitals posture arm recoil scarf sign

arm recoil scarf sign Explanation: Arm recoil and the scarf sign are used to evaluate neuromuscular maturity. Physical maturity indicators include skin, lanugo, plantar surface, breast, eye-ear, and genitals.

The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location? between the umbilicus and symphysis pubis at the level of the umbilicus one fingerbreadth below the umbilicus 2 cm above the umbilicus

at the level of the umbilicus Explanation: After birth, the fundus is located midline between the umbilicus and symphysis pubis but then slowly rises to the level of the umbilicus during the first hour after birth. Then the uterus contracts, approximately 1 cm (or fingerbreadth) each day after birth.

It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at: the level of the umbilicus. between the umbilicus and symphysis pubis. 1 cm below the umbilicus. 2 cm below the umbilicus.

between the umbilicus and symphysis pubis. Explanation: The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. Approximately 6 to 12 hours after birth, the uterine fundus is usually at the level of the umbilicus. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal? heart rate of 90 to 100 bpm body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) rounded, symmetrical abdomen enlarged labia with pseudomenstruation positive Ortolani sign

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) Explanation: On average, a newborn's temperature ranges from 97.9° to 99.7° F (36.5° to 37.5° C).

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? bright red, raised bumpy area noted above the right eye small pink or red patches on the baby's eyelids and back of the neck fine red rash noted over the chest and back blue or purplish splotches on buttocks

bright red, raised bumpy area noted above the right eye Explanation: A red bumpy area noted above the right eye is a hemangioma and needs further investigation to determine whether the hemangioma could interfere with the infant's vision. They may grow larger during the first year then fade and usually disappear by age 9. Stork bites or salmon patches and blue or purple splotches on buttocks (Mongolian spots) are common skin variations and are not concerning. Erythema toxicum, seen as a fine red rash over the chest and back, is also a normal skin variant that will disappear withn a few days.

A primiparous mother gave birth to an 8 lb 12 oz (4 kg) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? formula feeding cephalohematoma female gender hepatitis A vaccine Rh positive blood type

cephalohematoma Explanation: Risk factors for the development of jaundice include bruising as seen in a cephalohematoma, male gender and being breastfed. Blood type incompatabliity is only an issue if the infant's blood type differs from the mother and the maternal blood type is not stated. Administering hepatitis A vaccine does not increase the risk of jaundice.

The ability of the nurse to identify irregular findings during a physical assessment aids in rapid diagnosis and treatment of possible complications. The nurse assesses a newborn and notes tachycardia. The nurse notifies the health care provider based on the understanding that further assessment is necessary for which condition? drug withdrawal infection hypothermia anemia

drug withdrawal Explanation: Tachycardia may be found with volume depletion, cardiorespiratory disease, drug withdrawal, and hyperthyroidism.

The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? ductus arteriosus foramen ovale ductus venosus umbilical vessels

ductus arteriosus Explanation: During fetal life, the ductus arteriosus protects the lungs against circulatory overload by shunting blood into the descending aorta, bypassing the pulmonary circulation. The foramen ovale is located in the septum between the atria and allowed blood to flow from the right atrium directly the left atrium. The ductus venous allowed the majority of the blood to bypass the liver. The umbilical vessels carried oxygenated blood to the fetus and removed deoxygenated blood and waste products from the fetus.

The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone? estrogen progesterone hCG prolactin

estrogen Explanation: The endocrine system rapidly undergoes several changes after birth. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. hCG and prolactin are not associated with postpartum diuresis.

What are common risk factors for developing newborn jaundice? Select all that apply. fetal-maternal blood group incompatibility prematurity breastfeeding certain drugs maternal gestational diabetes too frequent feedings

fetal-maternal blood group incompatibility prematurity breastfeeding certain drugs maternal gestational diabetes Explanation: Common risks factors for development of jaundice in the newborn include the following: fetal-maternal blood group incompatibility, breastfeeding, prematurity, certain drugs, infrequent feedings, maternal gestational diabetes, male gender, trauma during birth, certain infections and viruses, and Asian or Native American ancestry.

A nursing instructor explains to students that, regardless of their gestational age, all newborns experience the same pattern that includes which periods? Select all that apply. first period of reactivity period of increased responsiveness period of decreased responsiveness second period of reactivity third period of reactivity

first period of reactivity period of decreased responsiveness second period of reactivity

A nursing student will pick which value as a correct laboratory value for a newborn? hemoglobin (HBG) 17 to 20 g/dL hematocrit (HCT) 45% to 50% platelets 50,000 to 75,000/µL white blood cells (WBC)s 5 to 10,000mm³

hemoglobin (HBG) 17 to 20 g/dL Explanation: The normal laboratory values for a newborn include HGB 17 to 20g/dL, HCT 52% to 63%, platelets 100,000 to 300,000µL , RBCs 5.1 to 5.8, and WBCs 10 to 30,000/mm³3.

A nurse is assessing a breastfeeding client in the third week postpartum. During the physical exam, the nurse observes that the rugae in the vagina have not reappeared. Which factor would the nurse identify as the possible cause of delayed return of rugae? high circulating estrogen level low circulating progesterone level high circulating prolactin level low circulating oxytocin level

high circulating estrogen level Explanation: The nurse should identify high circulating estrogen levels as the possible cause of delayed return of rugae. Low circulating progesterone levels initiate lactation. High circulating prolactin levels increase secretion of milk. Oxytocin is responsible for stimulating contractions of the uterus.

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? hyperglycemia hypertension hypovolemia hypothyroidism

hypovolemia Explanation: The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.

A nursing instructor informs students that recent research has shown that delayed cord clamping provides which advantages? Select all that apply. improving the newborn's cardiopulmonary adaptation preventing childhood anemia increasing blood pressure preventing childhood obesity improving oxygen transport increasing red blood cell flow

improving the newborn's cardiopulmonary adaptation preventing childhood anemia increasing blood pressure improving oxygen transport increasing red blood cell flow

The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply. incomplete emptying of bladder bladder distention ambulation difficulty urinary retention perineal laceration

incomplete emptying of bladder bladder distention urinary retention Explanation: Many women have difficulty with feeling the sensation to void after giving birth if they have received an anesthetic block during labor, which inhibits neural functioning of the bladder. This client will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to episiotomy.

During an initial newborn assessment, the nurse recognizes certain signs need to be reported to the primary care provider as they indicate potential problems. Which signs might indicate a problem? Select all that apply. labored breathing generalized cyanosis flaccid body posture tachycardia, greater than 140 beats per minute tachypnea, greater than 50 breaths per minute

labored breathing generalized cyanosis flaccid body posture

A nurse is assessing a newborn's gestational age. Which parameter would the nurse evaluate to assess physical maturity? Select all that apply. lanugo genitals arm recoil scarf sign posture

lanugo genitals Explanation: Physical maturity indicators include skin, lanugo, plantar surface, breast, eye-ear, and genitals. Arm recoil, posture, and the scarf sign are used to evaluate neuromuscular maturity.

The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? at the third intercostal space adjacent to the midclavicular line at the midsternum, just below the suprasternal notch lateral to the midclavicular line at the fourth intercostal space at the fifth intercostal space at the right midclavicular line

lateral to the midclavicular line at the fourth intercostal space Explanation: The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply. lethargy low-pitched cry cyanosis skin rashes jitteriness

lethargy cyanosis jitteriness Explanation: The nurse should monitor the newborn for lethargy, cyanosis, and jitteriness. Low-pitched crying or rashes on the infant's skin are not signs generally associated with hypoglycemia.

A nurse is describing the many changes a newborn will go through during his or her first couple of weeks after birth. The nurse explains how the functions of the placenta are taken over by which organ? liver intestine cardiovascular system kidneys

liver Explanation: At birth, the newborn's liver, not the intestine, cardiovascular system, or kidneys, assumes the functions that the placenta handled during fetal life. This includes iron storage, carbohydrate metabolism, blood coagulation, and conjugation of bilirubin.

A urinalysis is done on a postpartum mother 24 hours after delivery. Which findings would be considered normal for this client? Select all that apply. moderate glycosuria mild ketonuria Occasional RBCs trace WBCs gross proteinuria

moderate glycosuria mild ketonuria Occasional RBCs trace WBCs Explanation: Urine in a client in the early postpartum period may display ketonuria secondary to dehydration or prolonged labor, glycosuria from the inability of the kidneys to filter properly immediately following delivery, and RBC's from lochia contamination. Gross proteinuria is an abnormal finding for a urinalysis of this client.

A nurse is assessing a newborn and observes the newborn bringing his hand up to his mouth. The nurse interprets this finding as which behavioral response? motor maturity orientation habituation self-quieting ability

motor maturity Explanation: Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Bringing the hand up to the mouth is an example of good motor organization. The response of newborns to stimuli is called orientation. They become more alert when they sense a new stimulus in their environment. Habituation is the newborn's ability to process and respond to visual and auditory stimuli. It is a measure of how well and appropriately an infant responds to the environment. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves.

The majority of skin variations are transient and fade or disappear with time. The nurse assesses a permanent skin variation in a newborn and counsels the parents to monitor it because of its link to potential childhood cancer. The nurse implements this counseling based on which finding? nevus flammeus erythema toxicum Mongolian spots nevus vasculosus

nevus flammeus Explanation: Nevus flammeus, also called a port wine stain, may be associated with structural malformations, bony or muscular overgrowth, and certain childhood cancers and should be monitored with periodic examinations. Erythema toxicum is a benign rash that resembles flea bites. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Nevus vasculosus is also called strawberry mark and is a benign capillary hemangioma that tends to resolve by age 3 without treatment.

When conducting a class for new parents, the nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which behavioral responses would the nurse integrate into the discussion? Select all that apply. orientation habituation self-quieting ability adequate feedings attachment to parents

orientation habituation self-quieting ability

A nurse is explaining to new parents about the numerous changes that occur shortly after birth to the newborn. When describing how the ductus arteriosus closes, the nurse explains that which factor is most important to assist in its closure? oxygen clamping the umbilical cord start breastfeeding immediately breathing

oxygen Explanation: The ductus arteriosus becomes functionally closed within the first few hours after birth. Oxygen is the most important factor in controlling its closure. Closure depends on the high oxygen content of the aortic blood resulting from aeration of the lungs at birth.

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience? postpartum baby blues postpartum anxiety postpartum reaction postpartum depression

postpartum baby blues Explanation: Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.

When assessing a postpartum woman, the nurse would find which factor to be most significant in identifying possible postpartum hemorrhage? pulse rate blood pressure cardiac output hematocrit

pulse rate Explanation: Tachycardia in the postpartum woman warrants further investigation. Typically, the postpartum woman is bradycardic for the first two weeks. In most instances of postpartum hemorrhage, blood pressure, and cardiac output remain increased because of a compensatory increase in heart rate. Red blood cell production ceases early in the puerperium, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

A nurse is explaining to a new mother that her newborn is susceptible to both dehydration and overhydration. The nurse integrates knowledge of which aspect as the underlying mechanism for this risk? Select all that apply. reduced number of nephrons at birth reduced glomerular filtration rate limited concentration ability immature acid-base regulation decreased ability to produce urine

reduced glomerular filtration rate limited concentration ability Explanation: A full complement of one million nephrons is present by 34 weeks gestation. The glomeruli and nephrons are functionally immature at birth, resulting in a reduced glomerular filtration rate (GFR) and limited concentrating ability. A limited ability to concentrate urine and the reduced GFR make the newborn susceptible to both dehydration and fluid overload. Frequently the newborn's kidneys are described as immature, but they are able to carry out their usual responsibilities and can handle the challenge of excretion and maintaining acid-base balance. The majority of term newborns void immediately after birth, indicating adequate renal function. Although the newborn's kidneys can produce urine, they are limited in their ability to concentrate it until about 3 months of age, when the kidneys mature more.

Client teaching is conducted throughout a client's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? resumption of intercourse activity resumption of prepregnancy diet signs and symptoms of infection infant formula selection

resumption of intercourse activity signs and symptoms of infection

A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques? period of decreased responsiveness second period of reactivity first period of reactivity There is no preferred time.

second period of reactivity Explanation: The second period of reactivity is the best time to teach about feeding, positioning for feeding, and diaper-changing techniques. It is also a good time for the parents to interact with the infant as well as examine the infant and ask questions.

Circumcision is a very personal decision for parents, and the nurse's major responsibility is to inform the parents of the risks and benefits of the procedure. The nurse needs to recognize that this is mainly which type of decision? social decision difficult decision family decision legal decision

social decision Explanation: The decision to circumcise is often a social one. The discussion involves cultural, religious, medical, and emotional considerations. Nurses must remain unbiased and unemotional as they present the facts to the parents.

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions? tetracycline ophthalmic ointment silver nitrate solution vitamin K gentamicin ophthalmic ointment

tetracycline ophthalmic ointment Explanation: Erythromycin or tetracycline ophthalmic ointment is the agent of choice for newborn eye prophylaxis. Silver nitrate solution was once used for eye prophylaxis, but it is no longer used because it has little efficacy in preventing chlamydial eye disease. Vitamin K is used to promote blood clotting in the newborn. Gentamicin is not used for newborn eye prophylaxis.

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing? the taking-in phase the taking-hold phase the binding-in phase the letting-go phase

the taking-hold phase Explanation: The taking-in phase is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. The binding-in phase is a distractor for this question.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type? first-degree laceration second-degree laceration third-degree laceration fourth-degree laceration

third-degree laceration Explanation: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? types of decelerations variability FHR baseline changes in baseline rhythm

types of decelerations variability Explanation: Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations as electronic fetal monitoring (EFM) can.

A nurse is reviewing the medical record of a postpartum woman in preparation for assessment. Which factor would the nurse identify as increasing the woman's risk for infection? Select all that apply. urinary stasis denuded endometrial arteries episiotomy white blood cell count 25,000/mm³ hemoglobin 11.0 g/100 mL

urinary stasis denuded endometrial arteries episiotomy Explanation: The urinary system after birth is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity, such as an episiotomy. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation. A hemoglobin finding lower than 10.5 g/100 ml suggests anemia

During an assessment, the nurse notes that the client has been unable to urinate properly since she gave birth and is still bleeding more than expected. The nurse suspects which condition? uterine atony urinary retention postpartum diaphoresis urinary tract infection

uterine atony Explanation: Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. The client will have increased diaphoresis as the body works to decrease the blood volume that was necessary during the pregnancy.

A nurse visiting a postpartum client at home is reviewing the need for the woman to meet her own nutritional needs. The woman is breastfeeding her newborn. The nurse determines that the client understands her nutritional needs based on which statements? Select all that apply. "I need to drink about 2 to 3 quarts of fluid each day." "I should have about 4 servings of fruits each day." "I need to eat about 7 servings of vegetables daily." "I will have at least 4 to 5 servings of milk each day." "I need to cut way back on any fats and oils daily."

"I need to drink about 2 to 3 quarts of fluid each day." "I should have about 4 servings of fruits each day." "I will have at least 4 to 5 servings of milk each day."

A mother's chart notes that she is non-immune on her rubella status. The nurse explains what this means to the client. Which statement by the mother indicates that more teaching is needed? "I need to have three shots to get my rubella levels up." "I may need to have a re-vaccination if I remain non-immune." "Rubella is bad disease that I need to immunized against." "I will get my rubella immunization before I leave the hospital."

"I need to have three shots to get my rubella levels up." Explanation: If a mother is non-immune to rubella, she will receive a rubella immunization prior to being discharged from the hospital. She will have titers drawn 6 to 8 weeks later to determine if she developed immunity to rubella. If she remains non-immune, she will receive a re-vaccination. There will only be two shots potentially, not three.

A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is the nurse's best response? "It is the measurement between the ischial tuberosity and the pubis." "It is a measurement to determine if the pelvis size is adequate for a vaginal birth." "It is the smallest diameter of the pelvic outlet." "It is the largest diameter of the pelvic outlet."

"It is a measurement to determine if the pelvis size is adequate for a vaginal birth."

During a home visit with new parents, the nurse also assesses the new father's adaptation to his new role. Which statement would indicate that he is in the expectation stage? "I didn't realize all that went into being a dad. I wasn't prepared for this." "It'll be fun to have a baby in the house, but things shouldn't change too much." "I've learned how to diaper and bathe the baby so I can be a really involved dad." "I may not be a pro at helping out with the baby, but I enjoy being involved."

"It'll be fun to have a baby in the house, but things shouldn't change too much." Explanation: The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.

Which assessment findings indicate a distressed fetus? Select all that apply. Absent accelerations Fetal heart rate baseline of 140 Late deceleration patterns Persistent bradycardia Moderate fetal heart rate variability

Absent accelerations Late deceleration patterns Persistent bradycardia Explanation: The nurse evaluates the fetal monitor for reassuring patterns and/or signs of fetal distress. Absent accelerations, late deceleration patterns and persistent bradycardia indicate client hypoxia. A fetal heart rate baseline of 140 and moderate variability is a reassuring sign.

A client is reporting considerable postpartum abdominal and perineal pain at a 7 on a scale of 1 to 10. The nurse will prioritize which action after noting the client is currently receiving ibuprofen 600 mg every 8 hours? Offer a hot pad for the abdomen. Apply a cold pack to the perineum. Administer acetaminophen with codeine. Assist the client to change position.

Administer acetaminophen with codeine. Explanation: Ibuprofen (600 to 800 mg) may be ordered to be given every 6 to 8 hours around the clock. This type of dosing is often more effective at keeping pain under control than is an "as-needed" schedule; however, a combination medication, such as acetaminophen with codeine, may be ordered on an as-needed basis for breakthrough pain. Applying either a hot pad or cold pack or changing positions are nonpharmacologic approaches which may be used to help with the pain if the client does not desire to take medication. It may also lessen the amount of pain medication that is needed to control the client's pain.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? an absence of lochia red-colored lochia for the first 24 hours lochia that is the color of menstrual blood lochia appearing pinkish-brown on the fourth day

An absence of lochia

The registered nurse has identified that the client's labor progress has slowed. Which nursing intervention, done by the practical nurse, is completed first? Assess the fetal heart rate Assess the strength of contraction Assess if the bladder is distended Assess the client's psyche

Assess if the bladder is distended Explanation: The nurse must consider causes impeding fetal descent. A full bladder may slow fetal descent. Encourage the client to void at least every 2 hours. Assessment of the fetal heart rate, contraction strength, and psyche is important to note but is not directly related to impeding the fetal descent.

The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0oF (36.1oC), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize? Check the infant's temperature again. Complete an entire set of vital signs. Assess the infant's blood sugar. Check oxygen saturation of the blood.

Assess the infant's blood sugar.

A client who gave birth 18 hours ago is experiencing a change in lochia flow from scant to moderate. Prioritize the actions the nurse would take to assess the client's fundus. All options must be used. 1 Assist the client to empty her bladder in the bathroom. 2 Palpate the fundus. 3 Massage the fundus if boggy. 4 Increase IV oxytocin or breastfeed the newborn. 6 Notify the primary care provider. 5 Assess blood pressure.

Assist the client to empty her bladder in the bathroom. Palpate the fundus. Massage the fundus if boggy. Increase IV oxytocin or breastfeed the newborn. Assess blood pressure. Notify the primary care provider.

A nurse works at a facility that provides care to clients holding various cultural beliefs. The nurse integrates understanding of the areas recognized by other cultures that are not necessarily acknowledged by the Western culture. Which area would the nurse need to incorporate into the plans of care? balance of hot and cold introducing the infant to the rest of the family allowing family members at the birth expectations of what the new mother should be doing

Balance of hot and cold

A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize? Immediately report to the RN that the FHR shows tachycardia. Immediately report to the RN that the FHR shows no variability. Before reporting to the RN, determine the short term variability (STV). Before reporting to the RN, determine the uterine contraction pattern.

Before reporting to the RN, determine the uterine contraction pattern. Explanation: The nurse needs to assess and determine if the changes are related to accelerations secondary to contractions. Assess the contraction pattern with the fetal heart rate and provide information to the RN. If the accelerations are not due to uterine contractions, notify the RN immediately. Until then, the nurse should do the assessment before reacting.

The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role as a mother by performing which actions of the first stage of adaptation? Maternal identify Physical restoration and learning to care for infant Shift in normal life to new normal Beginning attachment and preparation for family

Beginning attachment and preparation for family Explanation: The first stage is the beginning attachment to the fetus and idea of a family. This occurs during pregnancy. The four stages include: 1) beginning attachment and preparation for the infant during pregnancy; 2) increasing attachment, learning to care for the infant, and physical restoration during the early postpartum period; 3) moving toward a new normal in the first 4 months; and 4) achieving a maternal identity around 4 months.

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? Reassess the client in 1 hour. Document the lochia as scant. Ask when the peri-pad was changed. Massage the client's fundus.

Document the lochia as scant. Explanation: "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.

At which time in a client's labor process would the nurse encourage effleurage? At home as the client is determining true labor During the early labor phase During the active labor phase Immediately prior to birth

During the early labor phase Explanation: Effleurage, a form of touch therapy, is a technique that the client uses in early labor. Light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking pain sensation. This technique does not determine true labor, is not helpful in the active stage of labor (as contractions are more intense), nor is it done when the client is ready to give birth.

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply. Edema Redness Slight bruising Discharge Bleeding

Edema Slight bruising Explanation: During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness, bleeding or discharge.

A multigravida client is still focusing on her difficult labor and discusses it with the nurse at each opportunity, several hours after the birth. Which action should the nurse prioritize after noting the client's partner is spending more time with the infant than the client? Redirect her attention to the baby by reminding her of the details of newborn care. Ask her to describe how she plans to integrate the newcomer into her existing family, including any actions she has taken to prepare the siblings. Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. Point out positive features of her baby, and encourage her to hold and cuddle the baby.

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. Explanation: The client needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive, and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the client at this time.

A client has moved into the active phase of labor and is now at 6 cm dilated and +1 station. The nurse is prepared to monitor the contraction pattern how often? Every 10 minutes Every 15 minutes Every 30 minutes Every hour

Every 30 minutes Explanation: Active labor is a phase in the first stage of labor when the cervix dilates from 4 to 8 cm. The contractions are progressing and occur every 2 to 5 minutes and last 45 to 60 seconds. The nurse needs to evaluate the labor pattern every 30 minutes. During the latent phase of the first stage, the labor pattern should be evaluated every hour. During the transition phase of the first stage, the contraction pattern should also be evaluated every 30 minutes. During the second stage of labor, the contraction pattern should be evaluated every 15 minutes.

A nurse is making a home visit to a black woman who gave birth to a healthy newborn 4 days ago. When developing the plan of care for this woman, which considerations would the nurse need to integrate into the plan of care? Select all that apply. Extended family members may be involved with caring for the infant. Bathing the newborn may be postponed for the first week. The woman may avoid eye contact with the nurse who is making the visit. The woman may be reluctant to discuss measures related to birth control. Oils may be used on the newborn's skin and hair.

Extended family members may be involved with caring for the infant. Bathing the newborn may be postponed for the first week. Oils may be used on the newborn's skin and hair.

Which cardinal movement allows the fetus to travel through the birth canal most efficiently? Extension External rotation Flexion Engagement

Flexion Explanation: As the fetus progresses down the birth canal, flexion coaxes the fetus to assume the position of the smallest diameter of the fetal head to fit through the dimension of the pelvis. Extension and external rotation occurs later in the labor process before birth and passes the fetal head through the pubic arch to birth of the head. Engagement occurs when the fetal head descends to the level of the ischial spines and can occur 2 weeks prior to the initiation of labor.

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply. Inverted nipples following breastfeeding Fundus one fingerbreadth below the umbilicus Hypotonic bowel sounds Urination of 100 mL every 4 hours Moderate saturation of peripad every 3 hours

Fundus one fingerbreadth below the umbilicus Moderate saturation of peripad every 3 hours A fundus should be one fingerbreadth below the umbilicus at 24-hours postpartum, and moderate saturation of two-thirds of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and urination of100 mL every 4 hours is inadequate given the occurrence of diuresis.

A multiparous woman at 39 weeks' gestation arrives at the labor and delivery unit stating that she is in labor. Upon pelvic examination, the nurse documents a softening of the cervix and 3 cm dilation. Which nursing action is best? Have the client rest in bed on her left side. Have the client ambulate in the hall and recheck. Send the client home and return if contractions increase Admit the client directly to the labor and delivery area

Have the client ambulate in the hall and recheck. Explanation: To determine if the client is in true labor, the nurse is most correct to have her walk in the hall for approximately an hour. At that point, the client is rechecked to identify if labor has progressed. If labor has progressed, the client is admitted. Having the client rest in bed is not helpful to assist in labor progression.

The nurse is teaching a discharge session to a group of postpartum clients. When asked how long to expect the bleeding, which time frame should the nurse point out? For 6 weeks On and off for 2 to 3 weeks Stops in 1 to 2 weeks In approximately 10 days

In approximately 10 days

Which nursing instruction is best when helping the woman deliver the fetus in a controlled manner? Instruct the client to blow through the lips like blowing out candles. Instruct the client to bare down and push with each contraction. Instruct the client to change positions frequently. Instruct the client to limit fluid intake until after the second stage of labor.

Instruct the client to blow through the lips like blowing out candles. Explanation: To deliver the fetus in a controlled manner, the client expels the fetus without force, allowing the body to naturally birth the baby. To accomplish this, the nurse instructs the client to blow through the lips instead of holding the breath and bearing down. This adds force and pressure to the birth. Changing positions and limiting fluid does not impact the birth process. The client is typically supine or in the lithotomy positions for the birth.

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which actions would the nurse include in her discussion as possible strategies for the new mothers to do? Select all that apply. Kegel exercises avoid smoking lose weight if obese increase fluid intake start jogging

Kegel exercises avoid smoking lose weight if obese

After the abdominal dressing is removed 24 hours following a cesarean delivery, the nurse inspects the incision and observes drainage from the incision, redness along the suture line and moderate edema. Staples are intact. What action would the nurse take? Record the findings in the client's chart. Let the RN know of your findings. Since everything appears normal, continue to monitor the incision every 4 hours. Re-apply a dressing over the incision line.

Let the RN know of your findings. Explanation: All of the nurse's findings are abnormal except for the intact staples. The RN needs to be made aware of the appearance of the patient's incision, so she can contact the doctor for orders. Re-applying another dressing will not address the signs of infection that are present.

Which assessment finding 1 hour after birth should be reported to the health care provider? Fundus of uterus is palpable at the level of the umbilicus. Fundus is displaced to the right, and bladder is hard. Large, bruised hemorrhoids are protruding from the anal opening. Lochia rubra is saturating a pad every 45 to 60 minutes.

Lochia rubra is saturating a pad every 45 to 60 minutes. Explanation: The nurse should ask the woman to turn under her buttocks can be inspected to be certain blood is not pooling beneath her. If the nurse observes a constant trickle of vaginal flow or a woman is soaking through a pad every 60 minutes, she is losing more than the average amount of blood. She needs to be examined by her primary care provider to be certain there is no cervical or vaginal tear or that poor uterine contraction is not causing excessive bleeding. Following perineal assessment, the nurse should assess the rectal area for the presence of hemorrhoids. If any are present, the nurse should document their number, appearance, and size in centimeters. Fundus of uterus palpable at the level of the umbilicus is normal finding immediately after birth. When the fundus is displaced to right and bladder is hard to palpation, the bladder is full, and the nurse needs to assist client in emptying the bladder. The provider should be notified if a catheter needs inserted if there are no standing prescriptions for an in-and-out cath following birth.

When assessing a postpartum mother, the nurse asks the client how many peripads she has used over the last 4 hours. The mother responds that she has changed her pad 2 to 3 times per hour when they were saturated. What action should the nurse take? Notify the RN of the finding. Bring the mother more peripads to her bedside. Record the number of peripads on the client's chart. Encourage the mother to start massaging her fundus every hour.

Notify the RN of the finding. Explanation: If a mother reports that she is saturating more than one peripad per hour, the RN needs to be notified because this is too much bleeding. Having the mother massage the fundus after demonstrating how to do it is a good idea but her excessive bleeding is a much higher priority at this time.

The nurse is monitoring a client who is 3 hours postpatrum. On assessment the nurse notes a temperature of 102.4 oF. Which action should the LPN prioritize? Notify the RN; she will notify the provider. Administer an antipyretic. Assist the client in ambulation. Continue to monitor for another hour.

Notify the RN; she will notify the provider.

A 29-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next? Prepare the client for birth. Assess the client's cervical status. Notify the health care provider. Perform Leopold's maneuver.

Notify the health care provider. Explanation: The nitrazine tape shows a pH between 5 and 6, which indicates an acidic environment with the presence of vaginal fluid and less blood. If the membranes had ruptured, amniotic fluid was present, or there was excess blood, the nitrazine test tape would have indicated an alkaline environment. The nurse would notify the healthcare provider for further assessment of the client.

The multigravida client is moving into the transition phase and asks for a narcotic, stating she doesn't remember the pain being this bad before. Which response from the nurse will be best? "I will page the provider and ask for your pain medication." "You are so close to birth; don't you want to have natural birth?" Pain medication can affect the baby's breathing; let's try to focus and breathe." "Rather than use a narcotic, let's ask for a different type of pain medication."

Pain medication can affect the baby's breathing; let's try to focus and breathe." Explanation: Once the woman has entered into the transition phase of labor, she is considered to be imminent for birth. Any opioid medication might pass to the fetus and is not recommended due to the effects of respiratory compromise. The nurse will need to encourage nonpharmacologic methods at this point and should not consult the provider. The nurse should also remain supportive of the mother.

A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending? Alert the team that internal fetal monitoring may be needed. Palpate the area just above the symphysis pubis. Institute effleurage and apply pressure to the client's lower back during contractions. Encourage the client to push.

Palpate the area just above the symphysis pubis. Explanation: Palpate to determine if the infant is engaged and what the presenting part of the infant is by the symphysis pubis; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.

Which pelvic measurement is most important for the acceptance and passage of the fetal head during labor? False pelvis Pelvic outlet Ischial spines Pelvic inlet

Pelvic inlet Explanation: The pelvic inlet is the top portion of the pelvis where the head enters first. The pelvic outlet is where the fetus exits the mother. The false pelvis is above the true pelvis where the passageway begins. The ischial spines extend into the midpelvis.

When teaching an unlicensed assistant personnel (UAP) how to provide perineal care on a postpartum woman, the nurse would include which steps? Select all that apply. Wash hands and put on a pair of sterile gloves. Place a protective pad under the client's buttocks. Place the client in high-Fowler's position. Remove perineal pad in the direction of front to back. Separate labia and clean discharge using spray bottle.

Place a protective pad under the client's buttocks. Remove perineal pad in the direction of front to back. Explanation: Before beginning perineal care, the nurse should be certain to wash the hands well and pull on clean, not sterile, gloves. The nurse should then place a plastic-covered pad under the woman's buttocks to protect the bed from lochia or water. With the woman lying supine, the nurse should remove the perineal pad from front to back. A common method of cleaning is to spray the perineum with clear tap water from a spray bottle. When doing this, the nurse should direct the spray toward the front of the perineum and allow it to flow from front to back, from the vaginal to the rectal area, to reduce cross-bacterial transmission into the vagina. The labia have a tendency to close and cover the vaginal opening, and the nurse should not separate the labia.

The registered nurse and licensed practical nurse are working together on an admission to the labor and delivery suite. The client is at 37 weeks gestation and has had regular prenatal care without any complications. The client reports possible rupture of membranes. Of the six nursing responsibilities below, which three should be completed by the licensed practical nurse? Place the client on the fetal monitor Obtain the admission health history Height, weight, vital sign assessment Obtain a urine sample Complete a Nitrazine paper test Assess fetal monitor strip

Place the client on the fetal monitor Height, weight, vital sign assessment Obtain a urine sample

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? Promote early breastfeeding for the infants. Avoid skin-to-skin contact with the mother until the infants are 8 hours old. Keep the infant transporter temperature between 80 and 85 degrees F (27 and 29 degrees C). A void bathing the newborn until they are 24 hours old.

Promote early breastfeeding for the infants.

The nursing instructor is teaching a session on how labor starts.The instructor determines the session is successful when the class correctly chooses which causative factor that initiates labor? Progesterone levels rise at term to initiate contractions. The ovary releases additional estrogen at term. Prostaglandins may be the causative factor of labor. Oxytocin blood levels increase with contractions.

Prostaglandins may be the causative factor of labor. Explanation: The cause of labor is unknown, but prostaglandin release is theoretically one of the possible causes for onset of labor. It is unknown whether progesterone or estrogen initiate labor. Some scientists have proposed that a rise in oxytocin levels may be responsible for initiating labor; however, blood levels of oxytocin do not measurably increase before labor begins. Therefore, some researchers have concluded that oxytocin is probably not the main factor that stimulates labor to begin.

A woman gave birth yesterday to a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at birth. Which intervention would be the priority? Encourage the mother to care for herself. Review the causes of a cleft palate with the mother. Provide time for the mother to grieve for the loss of the perfect baby. Have the mother wait for a day or two to visit the child in the nursery.

Provide time for the mother to grieve for the loss of the perfect baby. Explanation: Grief is the response to loss. The process of mourning will take precedence over the mother's self-care in this initial period. The nurse will assess the mother to note her physical condition, but the mother will be focused on the child. The mother can be assisted to determine the appropriate time to see the child, and then attachment can be promoted.

A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means? Reassuring; it is associated with normal acid-base balance. Worrisome; it may be associated with metabolic acidosis. Critical; it represents metabolic acidosis. Damaging; it is frequently associated with fetal neurological damage.

Reassuring; it is associated with normal acid-base balance. Explanation: The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus.

The nurse is providing a report on a gravida 3 para 2 client. The nurse states that the client is fully effaced, 7 cm dilated, station +1, and contractions every 8 minutes. Which nursing action is most important at this time? Record tocodynamometer readings. Obtain vital signs. Discuss contraction intensity. Ambulate the client in the hall.

Record tocodynamometer readings

Parents tell the nurse that their 3-year-old son has begun to have "accidents" at home following the arrival of his baby sister and wants to sit in his mother's lap all the time now. What advice would the nurse offer these parents? Select all that apply. Tell the older sibling that he is a big boy and has to share his mommy with the little sister. Set aside time every day for the parents to focus on the big brother exclusively. Buy the older sibling a doll for him to care for, as the mother is caring for the new baby. Scold him whenever he wets his pants and place him back in diapers. Be aware of potential aggressive behaviors from the older sibling.

Set aside time every day for the parents to focus on the big brother exclusively. Buy the older sibling a doll for him to care for, as the mother is caring for the new baby. Be aware of potential aggressive behaviors from the older sibling.

A nurse is assessing a postpartal woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartal period? She sits and rocks her infant for long intervals. She is eager to talk about her birth experience. She has not asked for anything for pain all day. She did her perineal care independently.

She did her perineal care independently. Explanation: During the taking-in phase, women tend to be dependent; during the taking-hold phase, they begin independent actions.

The nurse is preparing to teach a group of new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens? Breech Shoulder Oblique lie Transverse lie

Shoulder

A postpartum client delivered her infant 1 day ago and the nurse is monitoring her blood pressure. What position would the nurse place the client in to get the most accurate reading? Lying flat in the bed on her back Lying on the right side for 5 minutes Sitting up in the bed Sitting on the side of the bed for 2 to 3 minutes

Sitting on the side of the bed for 2 to 3 minutes Explanation: In order to get the most accurate reading on a client's blood pressure, it is advised to have the client sit up on the side of the bed for several minutes to prevent orthostatic hypotension and a falsely low blood pressure.

The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction? Temp: 99.4° F (37.4° C), HR 90, RR 18, BP 112/67 Temp: 97.0° F (36.1° C), HR 80, RR 20, BP 120/72 Temp: 100.2° F (38° C), HR 65, RR 22, BP 130/78 Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85

Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85

A nurse is caring for a female client in labor who has chosen hydrotherapy as her pain management for labor. As the nurse prepares the client for this treatment, which procedure is recommended as the most appropriate consideration? The client should be in active labor. The client, once submerged, should not stay in the tub too long. The water temperature should exceed the client's body temperature. The client should not submerge in water until membranes are ruptured.

The client should be in active labor. Explanation: Most recommendations for hydrotherapy, or water therapy, include active labor. If the client is not in active labor, the contractions could slow because of relaxation of muscles. There is no time limit for water therapy; it is provided for comfort. The water temperature should not be higher than the maternal body temperature, and water therapy can be used with intact or ruptured membranes.

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring? The client who is having back labor and desires to lay on her side The client who is very restless and is moving around in the bed The client who has had a previous cesarean section The client who is having an uncomplicated labor

The client who is very restless and is moving around in the bed Explanation: The client who is restless and frequently changing positions is more likely to have continuous internal electronic fetal monitoring. This method provides data on the fetal heart rate. Depending upon the obstetric history, the client having back labor and the client with an uncomplicated labor may have intermittent fetal heart rate auscultation or external electronic fetal monitoring. The client who had a previous cesarean section would also have monitoring of uterine contraction intensity.

The nurse is looking at the latest lab work for her postpartum client. The clent's pre-delivery hemoglobin and hematocrit (H & H) was 12.8 and 39. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values? The client will need a transfusion, so the RN needs to be notified. The client will be tired, so encourage the her to sleep whenever the baby sleeps. The doctor needs to be notified of the latest lab values. These values are expected for a one-day postpartum mother.

The doctor needs to be notified of the latest lab values. Explanation: If there is a significant drop in a postpartum mother's H & H, the doctor needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The doctor will decide what measures to take.

Which change in client status suggests that labor is anticipated? The woman can breathe easier throughout the day. The woman does not have to urinate as often. Uterine contractions occur but diminish when resting. The woman is anxious about the birth process.

The woman can breathe easier throughout the day. Explanation: Symptoms that the woman is able to breathe easier strongly suggest lightening. Lightening means that the fetus has dropped into the pelvis or is engaged. Typically when the fetus is in the pelvis, it impinges on the bladder causing the need for more frequent urination. Braxton Hicks contractions are the first contractions which may be present for some time. These contractions occur but can diminish when walking or when position changes. Anxiety and anticipation is commonly felt throughout pregnancy.

The nurse is examining a newborn and notes that there is swelling on the newborn's head, limited to the right side of the head. How should the nurse interpret this finding? This is concerning since the swelling does not cross the suture lines. This is a cephalohematoma and will spontaneously resolve without interventions. This newborn is at higher risk of polycythemia due to the collected blood under the scalp. The newborn has a caput succedaneum that will go away within the first week of life.

This is a cephalohematoma and will spontaneously resolve without interventions. Explanation: The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the cephalohematoma crosses the suture lines, a skull fracture is suspected. The newborn is at higher risk of jaundice and anemia, not polycythemia. This is not a caput since there is blood accumulation under the periosteum and not tissue swelling.

The nurse is correct to instruct the active labor client on which type of patterned breathing? Slow paced breaths "in through the nose and out through the mouth". Transitioning breaths from "slow, deep breaths to quicker short breaths" at the contraction peak. Begin rhythmic "Short, quick breaths then blow out through pursed lips." Hold the breath throughout the contraction and have deep breaths in between.

Transitioning breaths from "slow, deep breaths to quicker short breaths" at the contraction peak. Explanation: A client who is in active labor varies her breathing technique to the modified-paced breathing which alters between slow, deep breaths to shorter and quicker breaths at the contraction peak. Slow paced breathing is for early labor and focuses on relaxation. Short quick breaths are used with more intense and frequent contractions. The client should not hold her breath until pushing begins.

The nurse is caring for a client who prefers resting on her back during the labor process. To facilitate client wishes, which nursing action is required? Raise the head of the bed Place the tocometer low on abdomen Utilize a wedge under one hip Elevate the knee gatch

Utilize a wedge under one hip Explanation: Changing positions frequently can help during the labor process. By placing a wedge under the client's hip, it decreases the likelihood of hypotension and allows the nurse to protect the fetus from decreased oxygenation and meet client wishes. This option is the only one in which the staff is meeting client wishes. The head of the bed may be elevated as needed. Depending upon the location of the fetus, the tocometer is placed where fetal heart tones are able to be heard. Rarely is the knee gatch elevated as it may slow blood flow.

Which assessment findings of the fetus during labor are reassuring? Select all that apply. Variability between 18-20 bpm Late decelerations Fetal heart baseline of 130 bpm Repeated variable decelerations Gradual increase in the fetal heart rate baseline

Variability between 18-20 bpm Fetal heart baseline of 130 bpm Explanation: Reassuring patterns suggest that the fetus is tolerating the labor. Both variability between 18-20 bpm and a baseline heart rate of 130 bpm are within normal limits. Both late and repeated variable decelerations are abnormal and may require further intervention. A gradual increase in the fetal heart rate baseline can signal a distressed fetus.

A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply. Walk alongside the client to the bathroom. Check her blood pressure after she stands up. Elevate the head of the bed for several minutes before getting her up. Sit her in a chair after getting out of bed before going to the bathroom. Frequently ask the client how her head feels.

Walk alongside the client to the bathroom. Elevate the head of the bed for several minutes before getting her up. Frequently ask the client how her head feels.

The nurse has been monitoring the progression of labor for a primipara. At which time is the nurse most correct to prepare for delivery? When the health care provider arrives When the client begins pushing When the fetus is crowning When full dilation is reached

When the fetus is crowning Explanation: The nurse is most correct to identify that preparing for delivery occurs when the perineum is bulging or the fetus is crowning in the primipara. Once the nurse identifies that the fetus is in this location, the nurse will prepare for delivery. This may include breaking the bed to form the delivery area. There is no relation of when the health care provider arrives and the delivery of the fetus. Some clients only push a couple of times and the fetus is delivered, not allowing enough time for preparation. Full dilation is an indicator that the labor has progressed but not the best indicator that delivery is close and preparation is required.

A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate? "You should notice a change in your respiratory status within the next 24 hours." "Everyone is different, so it is difficult to say when your respirations will be back to normal." "It usually takes about 3 months before all of your abdominal organs return to normal, allowing you to breathe normally." "Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy."

Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy."

Which feature would alert the nurse that the client is in the transition phase of labor? reduction of rectal pressure decrease in the bloody show enthusiasm in the client beginning urge to bear down

beginning urge to bear down Explanation: Starting of the urge to bear down is a feature associated with the transition phase of labor. The transition phase is the last phase of the first stage of labor. In this phase the process of cervical dilatation is completed. During this phase the client experiences an increase in rectal pressure, an increase in the bloody show, and an urge to bear down. The contractions are stronger and hence the client feels irritable, restless, and nauseous. The client feels enthusiastic during the latent phase and not the transition phase.

A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull that is smallest should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet? transverse (biparietal) occipitomental occipitofrontal suboccipitobregmatic

transverse (biparietal)

A nurse is making a home visit to the parents of a newborn. This is their first baby. During the visit, the nurse observes the parents interacting with their newborn and notes that they demonstrate responsible behaviors to promote the infant's growth and development. The nurse interprets this behavior as reflecting: centrality. contact. individualization. reciprocity.

centrality. Explanation: Centrality, which is a component of commitment, is demonstrated when the parents place the infant at the center of their lives, acknowledging and accepting their responsibility to promote the infant's safety, growth and development. Contact, a dimension of proximity, refers to the sensory experiences of touching, holding, and gazing at the infant. Individualization, a dimension of proximity, reflects parental awareness of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately. Reciprocity is the process by which the infant's abilities and behaviors elicit a parental response.

A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn? conduction and evaporation conduction and radiation convection and radiation convection and evaporation

convection and evaporation Explanation: Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss by convection happens when air currents blow over the newborn's body. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. Heat loss also occurs by radiation to a cold object that is close to, but not touching, the newborn.

A mother who just given birth has difficulty sleeping despite her exhaustion from labor. What are the causes of this inability to rest? Select all that apply. crying baby inability to get adequate pain relief frequent trips to the bathroom due to diuresis bottle-feeding excess fatigue and overstimulation by visitors

crying baby inability to get adequate pain relief frequent trips to the bathroom due to diuresis excess fatigue and overstimulation by visitors

A nurse is describing the many changes that will occur during the early postpartum period with a group of young parents. The nurse reviews common reports experienced as the woman's body returns to her prepregnancy state. The nurse determines that the teaching was successful when the participants identify which report as being most common during the first week that will indicate their fluid volume is returning to normal? diaphoresis nocturia urinary frequency urinary urgency

diaphoresis Explanation: The profuse diaphoresis is common during the early postpartum period. Many women will wake up drenched with perspiration. This diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. It is common, especially at night during the first week after birth. Nocturia, urinary frequency, or urinary urgency are not associated with this fluid shift.

Touch and massage can be helpful during labor. Which touch and massage methods are used in labor? Select all that apply. patterned breathing effleurage counterpressure water therapy

effleurage counterpressure Explanation: Effleurage, a form of touch that involves light circular fingertip movements on the abdomen, is a technique the client can use in early labor. Light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation. If the client is experiencing intense back labor, it is often helpful for the partner to give the client a massage over the lower back or to use the fists or palms of the hands to apply counterpressure.

Place the cardinal movements of labor in the order in which they occur from first to last. All options must be used. 1 engagement, then descent 2 flexion 3 internal rotation 4 extension 5 external rotation 6 expulsion

engagement, then descent flexion internal rotation extension external rotation expulsion

When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement? estrogen progesterone prolactin human chorionic gonadotropin (hCG)

estrogen Explanation: Decreased levels of estrogen are associated with breast engorgement and with the diuresis that occurs postpartum. Progesterone and hCG are not involved with breast engorgement. Prolactin levels remain elevated in the lactating woman for milk synthesis and secretion, but decrease within 2 weeks for the woman who is not breast-feeding.

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs? every 15 minutes every 30 minutes every 45 minutes every 1 hour

every 30 minutes Explanation: When a pregnant client is in the active phase of labor, the nurse should monitor the vital signs every 30 minutes. The nurse should monitor the vital signs every 30 to 60 minutes if the client is in the latent phase of labor and every 15 to 30 minutes during the transition phase of labor. Temperature is usually monitored every 4 hours in the active phase of labor.

A nurse practitioner is conducting an in-service education program for a group of nurses working in the labor and birth unit. The program is focusing on interpreting FHR patterns. The nurse practitioner determines that the teaching was successful when the group identifies which patterns as indicating abnormal fetal acid-base status? Select all that apply. fetal bradycardia sinusoidal pattern minimal variability recurrent late decelerations fetal tachycardia

fetal bradycardia sinusoidal pattern recurrent late decelerations Explanation: FHR patterns that are predictive of abnormal fetal acid-base status include fetal bradycardia, sinusoidal pattern, and recurrent late decelerations. Fetal tachycardia and minimal variability, although each needs evaluation and continued monitoring, are not predictive of abnormal fetal acid-base status.

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client? presence of lochia rubra fever more than 100.4° F (38° C) fundus is above the umbilicus fundus is firm

fever more than 100.4° F (38° C) Explanation: A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.

During a spontaneous vaginal birth several things need to occur to the fetus in sequence. As the fetus encounters resistance, what is its usual reaction? extension flexion internal rotation engagement

flexion Explanation: As the head descends during labor, the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. This resistance normally coaxes the fetus to assume an attitude of flexion. Flexion is the attitude that presents the smallest diameters of the fetal head to the dimensions of the pelvis.

Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? white blood cells: 5,000/mm3 hemoglobin: 17.5 g/dL platelets: 400,000/uL red blood cells: 3,500,000/uL

hemoglobin: 17.5 g/dL Explanation: Hemoglobin typically ranges from 17 to 20 g/dL. White blood cells are initially elevated soon after birth as a result of birth trauma, typically ranging from 10,000 to 30,000/mm3. The newborn's platelet count is the same as that for an adult, ranging between 100,000 and 300,000/uL. After birth, the red blood cell count gradually increases as the cell size decreases. Normal count ranges from 5,100,000 to 5,800,000/uL.

The nurse is making a home visit to a woman who is 5 days postpartum and has no reports. Which finding would concern the nurse and warrant further investigation? uterus 5 cm below umbilicus lochia rubra edematous vagina diaphoresis

lochia rubra Explanation: Lochia serosa is normal from days 3 to 10 postpartum. However, lochia rubra is present for about the first 3 days and is considered abnormal on the 5th postpartum day. By the fifth day postpartum day, the uterus should be approximately 5 cm below the umbilicus. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

A nurse is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. The nurse understands that which factors are causing the extreme pain in the client? Select all that apply. lower uterine segment distention fetus moving along the birth canal stretching and tearing of structures spontaneous placental expulsion dilation of the cervix

lower uterine segment distention stretching and tearing of structures dilation of the cervix

A new dad is alarmed at the shape of his newborn's head. Assessment reveals swelling at the area of the presenting part. The swelling crosses the suture lines. The nurse suspects which condition? molding caput succedaneum cephalohematoma closed anterior fontanelle

molding Explanation: The changed (elongated) shape of the fetal skull at birth as a result of overlapping of the cranial bones is known as molding. Along with molding, fluid can also collect in the scalp (caput succedaneum), or blood can collect beneath the scalp (cephalohematoma), further distorting the shape and appearance of the fetal head. Caput succedaneum can be described as edema of the scalp at the presenting part. This swelling crosses suture lines and disappears within 3 to 4 days. Cephalohematoma is a collection of blood between the periosteum and the bone that occurs several hours after birth. It does not cross suture lines and is generally reabsorbed over the next 6 to 8 weeks. The findings do not suggest a closed anterior fontanelle.

The nurse is teaching a group of nursing students about pharmacologic interventions for pain in labor. The teaching has been effective when the students state that complications associated with epidural and spinal anesthesia include which conditions? Select all that apply. pruritis maternal fever hypotension aspiration respiratory depression

pruritis hypotension respiratory depression Explanation: Hypotension is the most frequent side effect associated with epidural or intrathecal anesthesia. When narcotics are used in addition to anesthetics, pruritus is a common side effect. Respiratory depression is another possible side effect when narcotics are used for spinal and/or epidural anesthesia.

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment? proximity reciprocity commitment all of the above

reciprocity Explanation: Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (i.e., the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship.

When teaching a group of nursing students about the different types of pelvis, the nurse describes which features of a gynecoid pelvis? Select all that apply. round-shaped inlet straight sacrum dull ischial spines wide pubic arch convergent side walls

round-shaped inlet dull ischial spines wide pubic arch

A nurse is providing care to a postpartum client. Which client behavior would indicate to the nurse that she is in the letting-go phase? shows increased confidence when caring for the newborn talks about her labor experience to others around her points out specific features in the newborn shows independence with self-care

shows increased confidence when caring for the newborn Explanation: During the letting-go phase, the woman assumes responsibility and care for the newborn with increased confidence. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Independence with self-care is an important aspect of the taking-hold phase.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type? first-degree laceration second-degree laceration third-degree laceration fourth-degree laceration

third-degree laceration Explanation: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.