OB Exam 2

When is Lochia Rubra?

First 3 days postpartum

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:

8-10

When is Lochia Alba?

After 10 days postpartum

When does the taking hold phase occur?

Days 2-3 postpartum. Lasts 10 days or more.

A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate

Stop the infusion immediately

A pregnant woman diagnosed with syphilis comes to the clinic for a visit. The nurse discusses the risk of transmitting the infection to her newborn, explaining that this infection is transmitted to the newborn through what?

placenta

A nursing student is aware that fetal gas exchange takes place in which area?

pllacenta

T/F A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on...third stage of labor of 10 minutes

False

T/F A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for postpartum infection base on...labor of 12 hours

False

T/F One characteristic of a newborn with fetal alcohol syndrome would include...malformed ears and cataracts

False

Sign of cervical laceration

Fundus is firm but a steady flow of blood continues

T/F A 32 weeks' gestation newborn in the neonatal intensive care is being assessed for hyperbilirubinemia. One diagnostic test the nurse would expect to be done is...hemoglobin

True

T/F A client is experiencing postpartum hemorrhage shortly after the birth of the infant. One nursing intervention appropriate for this client is...monitor vital signs every 15 minutes

True

T/F A client is experiencing postpartum hemorrhage shortly after the birth of the infant. One nursing intervention appropriate for this client is...turn the client on the side and inspect the area under the buttocks for blood

True

T/F A client who is diagnosed with septic pelvic thrombophlebitis is prescribed heparin therapy by the health care provider. One nursing assessment the nurse should prioritize to begin each nursing shift is...clotting profiles

True

T/F A client who is diagnosed with septic pelvic thrombophlebitis is prescribed heparin therapy by the health care provider. One nursing assessment the nurse should prioritize to begin each nursing shift is...evidence of bleeding

True

T/F A client who is diagnosed with septic pelvic thrombophlebitis is prescribed heparin therapy by the health care provider. One nursing assessment the nurse should prioritize to begin each nursing shift is...pain

True

T/F A nurse is caring for a client with cardiovascular disease who has just given birth. One nursing intervention the nurse would perform when caring for this client is...auscultate heart sounds for abnormalities.

True

T/F A nurse is caring for a newborn with transient tachypnea. One nursing intervention the nurse should perform while providing supportive care to the newborn is...provide oxygen supplementation

True

T/F A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on...forceps birth

True

T/F A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on...labor of 1 1/2 hours

True

T/F 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. Other data needs to be collected in assessing this client for a DVT includes...note any reddened areas on the right calf

True

T/F During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. One finding would correlate with this suspicion is...green amniotic fluid is present at birth

True

T/F During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. One finding would correlate with this suspicion is...the newborn has labored abdominal respirations

True

Leading cause of postpartum hemorrhage

Uterine atony

The RN should look for signs and symptoms of what potential problem during induction of labor?

Uterine tetany

Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic change influences breast engorgement? a. An increase in blood and lymph supply to the breasts b. An increase in estrogen and progesterone levels c. A dramatic increase in colostrum production d. Fluid retention in the breasts due to the intravenous fluids given during labor

a. An increase in blood and lymph supply to the breasts

After birth, the nurse would expect which fetal structure to close as a result of increases in the pressure gradients on the left side of the heart? a. Foramen ovale b. Ductus arteriosus c. Ductus venosus d. Umbilical vein

a. Foramen ovale

Which assessment finding indicates positive bonding between the parents and their newborn? a. Holding the infant close to the body b. Having visitors hold the infant c. Buying expensive infant clothes d. Requesting that the nurses care for the infant

a. Holding the infant close to the body

The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk of what? a. respiratory distress syndrome b. bottle mouth syndrome c. sudden infant death syndrome d. GI regurgitation syndrome

c. sudden infant death syndrome

Which newborn could be described as breathing normally? A. Newborn A is breathing deeply with a regular rhythm at a rate of 20 bpm. B. Newborn B is breathing diaphragmatically with sternal retractions at a rate of 70 bpm. C. Newborn C is breathing shallowly with 40-second periods of apnea and cyanosis. D. Newborn D is breathing shallowly at a rate of 36 bpm with short periods of apnea.

D. Newborn D is breathing shallowly at a rate of 36 bpm with short periods of apnea

A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation?

Decreased fetal oxygenation

Sub-involution

Delayed return of the uterus to its pre- pregnancy size and function

T/F Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5 Ts tool will recognize one potential cause of postpartum hemorrhage as...tissue

true

A postpartum client reports urinary frequency and burning. What cause would the nurse suspect?

urinary tract infection

T/F A pregnant client is admitted to a health care facility after her laboratory results reveal elevated liver enzymes, thrombocytopenia, and low hemoglobin and hematocrit. One assessment finding the nurse should prioritize for this client is...epigastric pain and tenderness

True

T/F A pregnant client is admitted to a health care facility after her laboratory results reveal elevated liver enzymes, thrombocytopenia, and low hemoglobin and hematocrit. One assessment finding the nurse should prioritize for this client is...generalized edema

True

T/F One characteristic of a newborn with fetal alcohol syndrome would include...hyperactive behavior and feeding problems

True

T/F One characteristic of a newborn with fetal alcohol syndrome would include...microcephaly and thin upper lip

True

T/F The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. One problem the nurse would include in the teaching is...polyhydramnios

True

A nurse is caring for a pregnant client who is HIV positive. What is a priority issue that the nurse should discuss with the client?

the need for the client to avoid breastfeeding

The nurse is explaining phototherapy to the parents of a newborn. The nurse would include what as the purpose? a. Increase surfactant levels b. Stabilize the newborn's temperature c. Destroy Rh-negative antibodies d. Oxidize bilirubin on the skin

d. Oxidize bilirubin on the skin

A woman in labor for over 12 hours has made very little progress. The health care provider thinks that her contractions lack the force needed to propel the infant downward through the birth canal. The provider asks a group of nursing students which hormone may need to be given to increase the force of the contraction. Which hormone would be the best answer?

oxytocin, a posterior pituitary hormone

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time?

Apply an ice pack to the perineal area.

The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving oxytocin and magnesium sulfate. The nurse will continue to monitor this client for progression to which condition?

preeclampsia

The nurse is caring for a client with preeclampsia and understands the need to auscultate this client's lung sounds every 2 hours to detect which condition?

pulmonary edema

A 19-year-old nulliparous woman is in early labor with erratic contractions. An assessment notes that she is remaining at 3 cm. There is also a concern that the uterus is not fully relaxing between contractions. The nurse suspects which complication?

reduced oxygen to the fetus

T/F A new mother delivered one week ago and is tearful, anxious, sad and has no appetite. She is diagnosed with postpartum blues. One factor that contributes to this problem is...lack of activity

False

T/F A new mother is diagnosed with a venous thromboembolism in her left calf. One risk factor associated with this problem is...precipitous birth

False

T/F A nurse is caring for a newborn with transient tachypnea. One nursing intervention the nurse should perform while providing supportive care to the newborn is...massage the newborn's back

False

T/F A nurse is caring for a newborn with transient tachypnea. One nursing intervention the nurse should perform while providing supportive care to the newborn is...provide warm water to drink

False

T/F A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on...hemoglobin 8.0 g/dL (80.0 g/L)

False

T/F A nurse suspects the a pregnant client may be experiencing a placental abruption (abruptio placentae). One finding that would support this suspicion is...insidious onset

False

T/F 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. Other data needs to be collected in assessing this client for a DVT includes...have the mother actively flex both legs for equal movement

False

T/F A postpartum woman is concerned about constipation following delivery. One factor that contributes to this problem is...poor diet after delivery

False

T/F A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. One finding that would lead the nurse to suspect that the woman is developing an infection is...fetal bradycardia

False

T/F During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. One finding would correlate with this suspicion is...the anterior fontanels (fontanelles) are sunken at birth.

False

T/F One finding the nurse should report to the health care provider for a postpartum client who delivered 12 hours ago is...lochia rubra

False

T/F The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. One problem the nurse would include in the teaching is...cystic fibrosis

False

T/F The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. One problem the nurse would include in the teaching is...decreased birth weight

False

T/F The nurse is monitoring a client at 36 weeks' gestation who is bleeding. The nurse is preparing to insert a Foley catheter. One explanation the nurse should provide the client regarding the need for a urinary catheter is..."Since you are unable to get out of bed, the catheter will keep you dry."

False

T/F The nurse is monitoring a client at 36 weeks' gestation who is bleeding. The nurse is preparing to insert a Foley catheter. One explanation the nurse should provide the client regarding the need for a urinary catheter is..."The catheter makes it easier to keep your perineal area clean during the birth of your baby."

False

T/F The nurse reviews the notes from the electronic health record of the newborn. One finding the nurse identifies that increases the newborn's risk for hypoglycemia is...weight and length

False

T/F While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios. Information the nurse would use to support this suspicion is...fundal height below that for expected gestational age

False

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRoberts maneuver

A newborn is exhibiting symptoms of withdrawal and toxicology test have been prescribed. Which type of specimen should the nurse collect to obtain the most accurate results?

Meconium

The nurse is developing a plan of care for a woman experiencing dystocia. Which nursing intervention would be the nurse's highest priority?

Monitoring the fetal heart rate patterns

Risks/causes of uterine atony

Multiple gestation LGA Polyhydramnios Overuse of oxytocin

A client is experiencing urinary incontinence. The nurse is teaching the client measures to regain control of the urinary sphincter. The nurse determines that the teaching was effective when the client states she will perform which action?

Perform Kegel exercises daily.

A women is bearing down uncontrollably say the baby is coming. What is the priority?

Prepare for immediate delivery

A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?

Prevent maternal seizures

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor?

Provide ongoing communication about what is happening.

A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

Respiratory depression, hypotension, absent tendon reflexes

A nurse is providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching?

She is at increased risk for type 2 diabetes mellitus after her baby is born.

A primigravida patient has been pushing for 2 hours. When the head emerges the fetus fails to deliver, the physician notes that the turtle sign has occurred. Which should be a nurse's interpretation of this?

Shoulder dystocia

A client has been referred for a colposcopy by the primary care provider. The client wants to know more about the examination. Which information regarding a colposcopy should the nurse give to the client?

The test is conducted because of abnormal results in a Papanicolaou test.

A client has been admitted to the birthing suite in labor. She has been in labor for 12 hours and is dilated to 4 cm. The primary care provider notes that the client is in hypotonic labor. What does this mean?

The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix.

The nurse is preparing a teaching session for a client considering tubal ligation. Which factor should the nurse prioritize in this session?

This is a permanent and irreversible procedure for birth control.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?

To check for postpartum hemorrhage

T/F A 32 weeks' gestation newborn in the neonatal intensive care is being assessed for hyperbilirubinemia. One diagnostic test the nurse would expect to be done is...bilirubin levels

True

T/F A client reports bright red, painless vaginal bleeding during the 32nd week of pregnancy. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. One immediate care measure initiated is...attach external monitoring equipment to record fetal heart rate sounds and kick counts

True

T/F A nurse is caring for a client with cardiovascular disease who has just given birth. One nursing intervention the nurse would perform when caring for this client is...assess for shortness of breath.

True

T/F A nurse is caring for a newborn with hypoglycemia. One symptom of hypoglycemia the nurse should monitor for in the newborn is...cyanosis

True

T/F A nurse is caring for a newborn with hypoglycemia. One symptom of hypoglycemia the nurse should monitor for in the newborn is...jitteriness

True

T/F A nurse is caring for a newborn with transient tachypnea. One nursing intervention the nurse should perform while providing supportive care to the newborn is...ensure the newborn's warmth

True

T/F A nurse is caring for a newborn with transient tachypnea. One nursing intervention the nurse should perform while providing supportive care to the newborn is...observe respiratory status frequently

True

T/F A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on...labor induction with oxytocin

True

T/F A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for postpartum infection base on...placenta requiring manual extraction

True

T/F A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify one sign as needing to be reported as...refuse feeding

True

T/F A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify one sign as needing to be reported as...temperature of 38.3° C (101° F) or higher

True

T/F 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. Other data needs to be collected in assessing this client for a DVT includes...measure the diameter of both calves

True

T/F A postpartum woman is concerned about constipation following delivery. One factor that contributes to this problem is...hemorroidal discomfort

True

T/F A postpartum woman is concerned about constipation following delivery. One factor that contributes to this problem is...iron supplements

True

T/F A postpartum woman is concerned about constipation following delivery. One factor that contributes to this problem is...perineal pain

True

T/F A pregnant client is admitted to a health care facility after her laboratory results reveal elevated liver enzymes, thrombocytopenia, and low hemoglobin and hematocrit. One assessment finding the nurse should prioritize for this client is...nausea and vomiting

True

T/F A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. One finding that would lead the nurse to suspect that the woman is developing an infection is...cloudy malodorous fluid.

True

T/F A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. One finding that would lead the nurse to suspect that the woman is developing an infection is...elevated maternal pulse rate

True

T/F A woman birthed her infant 24 hours ago by cesarean. One assessment finding that should be reported to the assigned nurse is...the client reports breakthrough pain level of 7 to 8

True

T/F During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. One finding would correlate with this suspicion is...the newborn makes bearing down movements

True

T/F One characteristic of a newborn with fetal alcohol syndrome would include...congenital cardiac defects and SGA

True

T/F One intervention the nurse would take to reduce the incidence of infection in a postpartum woman is...encourage intake of fluids before delivery and after discharge

True

T/F One intervention the nurse would take to reduce the incidence of infection in a postpartum woman is...teach proper positioning of the the infant for breastfeeding

True

T/F One intervention the nurse would take to reduce the incidence of infection in a postpartum woman is...wash her hands before and after caring for the client

True

T/F Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5 Ts tool will recognize one potential cause of postpartum hemorrhage as...thrombin

True

T/F The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. One problem the nurse would include in the teaching is...hypertension

True

T/F The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. One problem the nurse would include in the teaching is...increased risk of spontaneous abortion (miscarriage)

True

T/F The nurse is monitoring a client at 36 weeks' gestation who is bleeding. The nurse is preparing to insert a Foley catheter. One explanation the nurse should provide the client regarding the need for a urinary catheter is..."If urine output is less than 30 ml per hour, it is a sign of hemodynamic instability."

True

T/F The nurse is orienting in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. One symptom the preceptor would describe to the new nurse as a sign of severe preeclampsia is...blood pressure above 160/100 mm Hg

True

T/F The nurse is orienting in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. One symptom the preceptor would describe to the new nurse as a sign of severe preeclampsia is...hyperactive deep tendon reflexes

True

T/F The nurse is reviewing the notes for a newborn. One finding that would alert the nurse to further assess the newborn's respiratory status is...temperature

True

T/F The nurse performs a physical examination on a newborn 2 hours after birth. One finding that would indicate a need for a pediatric consultation is...absent moro reflex when startled

True

T/F The nurse performs a physical examination on a newborn 2 hours after birth. One finding that would indicate a need for a pediatric consultation is...yellow blanching of the skin when pressure applied to the nose

True

T/F The nurse reviews the notes from the electronic health record of the newborn. One finding the nurse identifies that increases the newborn's risk for hypoglycemia is...length of the labor

True

The nurse notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation (dilatation). Assessment reveals a prolapsed umbilical cord. Which action should the nurse prioritize?

Use fingers to press upward on the presenting part.

A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

are unable to shiver effectively to increase heat production.

It is determined that a patients blood Rh is negative and her partners in positive. To help prevent isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?

at 28 weeks gestation and again within 72 hours after delivery

The nurse is caring for term neonate who was exposed to cocaine throughout the pregnancy. What effect would this exposure have on the neonate's vital signs? a. They would be lower than normal b. They would be higher than normal c. They would not be affected at all d. BP would be lower, pulse would be higher

b They would be higher than normal

After the nurse provides instructions to a postpartum woman about postpartum blues, which statement indicates understanding? a. "I will need to take medication daily to treat the anxiety and sadness." b. "I will call the OB support line only if I start to hear voices." c. "I will contact my doctor if I become dizzy and fell nauseated." d. "I will feel like laughing one minute and crying the next minute."

b. "I will call the OB support line only if I start to hear voices."

A couple is considered infertile after how many months of trying to conceive? a. 6 months b. 12 months c. 18 months d. 24 months

b. 12 months

Which suggestion would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. Increase fluid intake and acid-producing foods in her diet. b. Avoid empty-calorie foods, breastfeed, and increase exercise. c. Start a high-protein, low-carbohydrate diet, and restrict fluids. d. Eat no snacks or carbohydrates after dinner.

b. Avoid empty-calorie foods, breastfeed, and increase exercise

What activity will increase a woman's risk of CVD if she is taking oral contraceptives? a. Eating a high-fiber diet b. Smoking cigarettes c. Taking daily multivitamins d. Drinking alcohol

b. Smoking cigarettes

The nurse is educating a female client with a history of human papillomavirus (HPV). Which information would the nurse include in the education plan regarding reproductive health?

"You should be sure to receive consistent testing for cervical cancer."

A woman in active labor has just had her membranes ruptured to speed up labor. The nurse is concerned the woman is experiencing a prolapse of the umbilical cord when the nurse notices which pattern on the fetal heart monitor?

variable deceleration pattern

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth

A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide?

"This is meconium-stained fluid from the baby."

T/F A nurse is caring for a client with cardiovascular disease who has just given birth. One nursing intervention the nurse would perform when caring for this client is...monitor the client's hemoglobin and hematocrit.

False

T/F A nurse is caring for a newborn with hypoglycemia. One symptom of hypoglycemia the nurse should monitor for in the newborn is...low pitched cry

False

T/F A nurse is caring for a newborn with hypoglycemia. One symptom of hypoglycemia the nurse should monitor for in the newborn is...skin rashes

False

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?

Ineffective airway clearance related to mucus and secretions

T/F A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for postpartum infection base on...hemoglobin level of 10 g/dL (100 g/L)

True

T/F On parameter measured in determining an APGAR score is...skin color

True

T/F While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios. Information the nurse would use to support this suspicion is...difficulty obtaining fetal heart rate

True

T/F While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios. Information the nurse would use to support this suspicion is...history of diabetes.

True

A laboring patient is experiencing dyspnea, diaphoresis, tachycardia, and hypotension. The nurse suspects aortocaval compression. What intervention should the nurse implement immediately

Turning the patient on her left side

A young client gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?

Twin-to-twin transfusion syndrome (TTTS)

A prophylactic agent is instilled in both eyes of all newborns to prevent which conditions? a. Gonorrhea and chlamydia b. Thrush and enterobacter c. Staphylococcus and syphilis d. Hepatitis B and herpes

a. Gonorrhea and chlamydia

A woman with HPV is likely to present with which nursing assessment finding? a. Profuse, pus-filled vaginal discharge b. Clusters of genital warts c. Single painless ulcer d. Multiple vesicles on genitalia

b. Cluster of genital warts

What is the initial intervention after a precipitous birth?

Establish airway on neonate

General signs of postpartum hemorrhage

Excessive bleeding Boggy fundus that does not respond to massage Abnormal clots Increased HR Decreased BP Decreased LOC

T/F Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5 Ts tool will recognize one potential cause of postpartum hemorrhage as...technique of birth

False

T/F Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5 Ts tool will recognize one potential cause of postpartum hemorrhage as...time

False

T/F While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios. Information the nurse would use to support this suspicion is...identifiable fetal parts on abdominal presentation

False

T/F A new mother delivered one week ago and is tearful, anxious, sad and has no appetite. She is diagnosed with postpartum blues. One factor that contributes to this problem is...hormonal changes

True

T/F A new mother is diagnosed with a venous thromboembolism in her left calf. One risk factor associated with this problem is...cesarean birth

True

T/F A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for postpartum infection base on...history of diabetes

True

T/F During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. One finding would correlate with this suspicion is...the newborn has green staining of the fingernails

True

The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. One intervention the nurse would include is...maintaining NPO status for the first day or two.

True

T/F The nurse reviews the notes from the electronic health record of the newborn. One finding the nurse identifies that increases the newborn's risk for hypoglycemia is...medication administers

True

A couple reports that the condom broke while they were having sexual intercourse last night. What would you advise to prevent pregnancy? a. Inject a spermicidal agent into the woman's vagina immediately. b. Obtain emergency contraceptives and take them immediately. c. Douche with a solution of vinegar and hot water tonight. d. Take a strong laxative now and again at bedtime.

b. Obtain emergency contraceptives and take them immediately

When interacting with parents caring for their newborn in opioid withdrawal, which nursing action is most essential?

Instruct the parents with a nonjudgmental, caring attitude.

The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?

It keeps alveoli from collapsing with breaths.

Because the newborn's RBCs break down much sooner than those of an adult, what might result?

Jaundice

T/F A nurse suspects the a pregnant client may be experiencing a placental abruption (abruptio placentae). One finding that would support this suspicion is...rigid uterus

True

The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize?

Assess the Rh of the baby.

A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse?

"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."

The nurse notes uterine atony in the postpartum client. Which assessment is completed next?

Assessment of the perineal pad

A mother is postpartum 2 hours after a cesarean birth with epidural anesthesia. The nurse notes the urine output in the Foley bedside drainage bag is 50 ml. What should the nurse do first?

Check the catheter tubing for kinks or obstruction.

A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor?

Chromosomal defects in the fetus

When does the taking in phase occur?

Days 1-2 postpartum

Uterine atony

Marked hypotonia of the uterus

Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next?

Massage the client's fundus.

A nurse is educating a 25-year-old client with a family history of cervical cancer. Which test should the nurse inform the client about to detect cervical cancer at an early stage?

Papanicolaou test

What are the 4 T's of postpartum hemorrhage?

Tone Trauma Tissue Thrombin

A nurse is caring for a woman who is being evaluated for a suspected malpresentation. The fetus's long axis is lying across the maternal abdomen, the contour of the abdomen is elongated. Which should the nurse's documentation of the lie of the fetus?

Transverse

T/F On parameter measured in determining an APGAR score is...reflex irritability

True

What does lochia alba look like?

White/tan

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth

In what infant would the nurse would be most alert for the development of transient tachypnea? a. Infant born b cesarean section b. Neonate who received no sedation c. Newborn of a mother with heart disease d. Baby who is small for gestational age

a. Infant born by cesarean section

A nurse observes a 3-day-old term newborn who is starting to appear mildly jaundiced. What might explain this condition? a. Physiologic jaundice secondary to breastfeeding b. Hemolytic disease of the newborn due to blood incompatibility c. Exposing the newborn to high levels of oxygen d. Overfeeding the newborn with too much glucose water

a. Physiologic jaundice secondary to breastfeeding

The major purpose of the first postpartum home care visit is to do what? a. identify complications that require interventions. b. obtain a blood specimen for PKU testing. c. complete the official birth certificate. d. support the new parents in their parenting roles.

a. identify complications that require interventions

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as:

acrocyanosis

A nurse is caring for a pregnant client with asthma. Which intervention would the nurse perform first?

assessing oxygen saturation

An female adolescent is diagnosed with gonorrhea. When developing the plan of care for this adolescent, the nurse would expect that she would also receive treatment for what?

chlamydia

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

hemorrhage

An insulin-dependent diabetic woman will require higher doses of insulin as which of the following pregnancy hormones increases in her body?

human placental lactogen

Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as:

milia

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor

A pregnant client presents to the emergency department reporting back-to-back contractions. Within 2 hours, the client is completely effaced and 9 cm dilated, and the fetal head is showing. Within minutes the client gives birth with only the nurse in attendance. This is an example of which occurrence?

precipitate labor

A client pregnant with twins comes to the clinic for an evaluation. While assessing the client, the nurse would be especially alert for signs and symptoms for which potential problem?

preeclampsia

The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which area because of the woman's increased risk?

preeclampsia

The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest?

promoting skin-to-skin contact (kangaroo care) on the chest

A nurse is auscultating the lungs of a postpartum client and notices crackles and some dyspnea. The client's respiratory rate is 12 breaths/minute; she appears in some distress. What complication should the nurse suspect based on these data?

pulmonary edema

The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving betamethasone and magnesium sulfate. The nurse recognizes the client is being treated for which condition?

severe preeclampsia

A nurse is providing care to a newborn. The nurse suspects that the newborn is developing sepsis based on which assessment finding?

temperature instability

Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition?

thromboembolism

When is Lochia Serosa?

3-10 days postpartum

A middle-aged woman is seen in the OB/GYN clinic and reports abdominal bloating, fatigue, abdominal pain, urinary frequency, and constipation. She also says that she had lost 24 pounds in the last month without trying to lose. For which disease should the primary care provider screen this client?

ovarian cancer

T/F One finding the nurse should report to the health care provider for a postpartum client who delivered 12 hours ago is...white blood cell count of 28,000/mm3

False

T/F One intervention the nurse would take to reduce the incidence of infection in a postpartum woman is...recommend that the mother changes her peripads every 12 hours

False

A patient has prolonged rupture of membranes. The RN should monitor for what condition?

Infection

A nurse who is conducting sessions on preventing the spread of sexually transmitted infections (STIs) discovers that there is a very high incidence of hepatitis B in the community. Which measure should the nurse take to ensure the prevention of the disease?

Instruct people to get vaccinated for hepatitis B.

Which of the following contraceptive methods offers protection against sexually transmitted infections (STIs)? a. Oral contraceptives b. Withdrawal c. Latex condom d. Intrauterine system

c. Latex condom

Which finding would lead the nurse to suspect that a postpartum woman was developing a complication? a. Fatigue and irritability b. Perineal discomfort and pink discharge c. Pulse rate of 60 bpm d. Swollen, tender, hot area on the breast

d. Swollen, tender, hot area on the breast

A nurse is caring for an antenatal client diagnosed with umbilical cord prolapse. For which condition should the nurse monitor the fetus?

fetal hypoxia

A nurse is preparing for a class to teach pregnant women and their partners about postpartum complications. Which measure would be most important for the nurse to emphasize as helping to prevent postpartum infection?

handwashing

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

hemorrhage

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

hypothermia

A client with ovarian cancer is admitted to the hospital for surgery. The nurse is completing a health history on the client. What clinical manifestations would the nurse expect to assess?

increased abdominal girth

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy?

methotrexate

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

respiratory and cardiovascular

During the assessment of a laboring client, the nurse learns that the client has cardiovascular disease (CVD). Which assessment would be priority for the newborn?

respiratory function

T/F A pregnant client is admitted to a health care facility after her laboratory results reveal elevated liver enzymes, thrombocytopenia, and low hemoglobin and hematocrit. One assessment finding the nurse should prioritize for this client is...watery diarrhea

False

T/F A pregnant client is admitted to a health care facility after her laboratory results reveal elevated liver enzymes, thrombocytopenia, and low hemoglobin and hematocrit. One assessment finding the nurse should prioritize for this client is...excessive weight loss

False

When assessing the substance-exposed newborn, which finding would the nurse expect? a. Calm facial appearance b. Daily weight gain c. Increasing irritability d. Feeding and sleeping well

c. Increasing irritability

A prenatal client who is 6 weeks' gestation calls the clinic to report vaginal bleeding. For what concern will the nurse further assess the client?

spontaneous abortion (miscarriage)

T/F A client comes to the clinic reporting swelling in the hands and feet, blurred vision, a pounding headache and nausea and vomiting. The client had a positive pregnancy test 15 weeks ago, but has had no prenatal care. This is the client's third pregnancy, and she says that her uterus never grew this big or this fast with the previous pregnancies. Based on the client's reason for seeking care, the nurse would collect additional data to rule out the presence of...missed abortion

False

T/F A client comes to the clinic reporting swelling in the hands and feet, blurred vision, a pounding headache and nausea and vomiting. The client had a positive pregnancy test 15 weeks ago, but has had no prenatal care. This is the client's third pregnancy, and she says that her uterus never grew this big or this fast with the previous pregnancies. Based on the client's reason for seeking care, the nurse would collect additional data to rule out the presence of...molar pregnancy

True

T/F A client at 36 weeks' gestation experiences vaginal bleeding. One condition that might be the cause of the client's bleeding is...placenta previa

True

T/F A client at 36 weeks' gestation experiences vaginal bleeding. One condition that might be the cause of the client's bleeding is...placental abruption (abruptio placentae)

True

T/F A nurse suspects the a pregnant client may be experiencing a placental abruption (abruptio placentae). One finding that would support this suspicion is...absent fetal heart tones

True

The nurse would expect a postpartum woman to experience lochia in which sequence? a. Rubra, alba, serosa b. Rubra, serosa, alba c. Serosa, alba, rubra d. Alba, rubra, serosa

b. Rubra, serosa, alba

When assessing a postpartum woman, which finding would lead the nurse to suspect postpartum blues? a. Panic attacks and suicidal thoughts b. Anger toward self and infant c. Periodic crying and insomnia d. Obsessive thoughts and hallucinations

c. Periodic crying and insomnia

Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? a. Hypothyroidism b. Cystic fibrosis c. Phenylketonuria d. Sickle cell disease

c. Phenylketonuria

When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and documents recent passing of meconium. These findings would indicate what? a. abnormal gastrointestinal newborn transition that requires reporting b. an intestinal anomaly that needs immediate surgery c. a patent anus with no bowel obstruction and normal peristalsis d. malabsorption syndrome resulting in fatty stools

c. a patent anus with no bowel obstruction and normal peristalsis

A nursing student asks the nursery nurse why they do not bathe the newborn immediately upon admission to the nursery observation area after birth. The nurse states that this would increase the risk of what? a. jaundice b. infection c. hypothermia d. anemia

c. hypothermia

A woman gave birth to a newborn via vaginal birth with the use of a vacuum extractor. The nurse would be alert for which possible effect in the newborn?

cephalohematoma

A client at 32 weeks' gestation has been admitted to the labor and birth unit with preterm labor. Which medication would the nurse be likely to administer to reduce the risk of complications in the preterm newborn?

corticosteroids

A nurse is providing care to a newborn who is receiving phototherapy. Which action would the nurse most likely include in the plan of care?

covering the newborn's eyes while under the phototherapy lights

At birth, a newborn's assessment reveals the following: heart rate of 140 bpm, loud crying, some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink body with blue extremities. The nurse would document the newborn's Apgar score as what? a. 5 points b. 6 points c. 7 points d. 8 points

d. 8 points

What is the Bishop score used to assess? a. Presence of bacterial vaginosis b. Amount of amniotic fluid present c. Overall fetal well-being in labor d. Cervical readiness for induction

d. Cervical readiness for induction

A sexually active 19-year-old presents to the clinic with postcoital bleeding, dysuria, and a yellow discharge. Her cervix upon exam is red and friable. What might the nurse suspect? a. Cervical cancer b. A tampon injury c. Primary syphilis d. Chlamydia

d. Chlamydia

When assessing the following women, who would the nurse identify as being at the greatest risk for preterm labor? a. Woman who had twins in a previous pregnancy b. Client living in a large city close to the subway c. Woman working full-time as a computer programmer d. Client with a history of a previous preterm birth

d. Client with a history of a previous preterm birth

Which measure helps prevent osteoporosis? a. Supplementing with iron b. Sleeping 8 hours nightly c. Eating lean meats only d. Weight-bearing exercise

d. Weight-bearing exercises

Which finding is indicative of hypothermia of the preterm neonate? a. Abdominal distention b. Acrocyanosis c. Depressed fontanels d. Nasal flaring

d. nasal flaring

A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate?

"Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed."

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony

A woman with known cardiac disease is in labor. In what position would the nurse place the client?

Semi-recumbent with a pillow under one hip

What is the order of lochia phases?

Rubra - Serosa - Alba

A nurse is preparing a presentation for a group of women which will cover various dietary and lifestyle changes to help avoid future pelvic structure changes. Which key point should the nurse point out in this presentation to the women?

Drink plenty of fluids each day.

The nurse is preparing discharge teaching for a client who is 2 days postpartum. Which action should the nurse prioritize to encourage prevention of constipation?

Encourage fiber-rich foods

The nurse administers a single dose of vitamin K intramuscularly to a newborn after birth to promote what? a. conjugation of bilirubin b. blood clotting c. foramen ovale closure d. digestion of complex proteins

b. blood clotting

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

conduction

A 10 week pregnant woman with diabetes has a glycosylated hemoglobin (HbA1c) level of 13%. At this tie the nurse should be most concerned about which possible fetal outcomes?

congenital anomalies

After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which student behavior indicates successful teaching? a. Transporting the newborn in an isolette b. Maintaining a warm room temperature c. Placing the newborn on a warmed surface d. Drying the newborn immediately after birth

d. Drying the newborn immediately after birth

The rationale for using a prostaglandin gel for a client prior to the induction of labor is to do what? a. stimulate uterine contractions b. numb cervical pain receptors c. prevent cervical lacerations d. soften and efface the cervix

d. soften and efface the cervix

A 25 year old patient is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heartbeat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for what?

dilation and curettage

A client who came to the clinic after finding a mass in her breast is scheduled for a diagnostic breast biopsy. Which response is most appropriate by the nurse while preparing the client for the procedure?

"During this procedure, a small sample of tissue will be removed for testing."

A client with genital herpes simplex infection asks the nurse, "Will I ever be cured of this infection?" Which response by the nurse would be most appropriate?

"There is no cure, but drug therapy helps to reduce symptoms and recurrences."

A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?

5% to 10% of their birth weight

Hematoma

Accumulation of blood in the connective tissue as a result of blood vessel damage

The neonate is crying, has a pink body with blue distal extremities, has flexed arms with clenched fists, heart rate of 154, and gags when the bulb syringe is used to suction. What would the nurse document the Apgar score as

Apgar is 9

What does APGAR stand for?

Appearance Pulse Grimace (cry/reflex irritability) Appearance Respirations

A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine the effectiveness of therapy?

Assess deep tendon reflexes.

At 37 weeks' gestation, a woman presents to labor and delivery complaining of intense, knife-like abdominal pain that started suddenly about 1 hour ago and has not subsided. On palpation, the abdomen is rigid and board-like and no vaginal bleeding is evident. What should the nurse do next?

Assess fetal heart rate

When caring for a client with premature rupture of membranes (PROM), the nurse observes an increase in the client's pulse. What should the nurse do next?

Assess the client's temperature.

A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilation (dilatation) to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point?

Bed rest to maintain pregnancy as long as possible

What does lochia rubra look like?

Bright red

A shoulder dystocia situation is called in room 4. The nurse enters the room to help and the health care provider says to the nurse, "McRoberts maneuver." What does the nurse do next?

Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis

What behaviors are expected during the taking hold phase?

Decreased dependency Eager to learn about the infant Vacillates between infant care and self care Desire to take charge

A patient presents a 28 weeks gestation and intact membranes. Contractions are 5 min apart over 60 min, 3 cm dilation, and 80% effaced. The RN should expect what medication to be administered?

Magnesium sulfate

A client has undergone a mastectomy for breast cancer. Which instruction should the nurse include in the postoperative client teaching plan?

Elevate the affected arm on a pillow.

A woman at 37 weeks' gestation presents to the labor and delivery area with symptoms of placental abruption (abruptio placentae). Which action should the nurse prioritize?

Ensure that large-bore IV access is obtained

Signs of cervical hematoma

Extreme pain Rectal pressure/urge to have bowel movement

T/F A 32 weeks' gestation newborn in the neonatal intensive care is being assessed for hyperbilirubinemia. One diagnostic test the nurse would expect to be done is...hematocrit

False

T/F A 32 weeks' gestation newborn in the neonatal intensive care is being assessed for hyperbilirubinemia. One diagnostic test the nurse would expect to be done is...sodium levels

False

T/F A client at 36 weeks' gestation experiences vaginal bleeding. One condition that might be the cause of the client's bleeding is...ectopic pregnancy

False

T/F A client at 36 weeks' gestation experiences vaginal bleeding. One condition that might be the cause of the client's bleeding is...spontaneous abortion (miscarriage)

False

T/F A client comes to the clinic reporting swelling in the hands and feet, blurred vision, a pounding headache and nausea and vomiting. The client had a positive pregnancy test 15 weeks ago, but has had no prenatal care. This is the client's third pregnancy, and she says that her uterus never grew this big or this fast with the previous pregnancies. Based on the client's reason for seeking care, the nurse would collect additional data to rule out the presence of...ectopic pregnancy

False

T/F A client comes to the clinic reporting swelling in the hands and feet, blurred vision, a pounding headache and nausea and vomiting. The client had a positive pregnancy test 15 weeks ago, but has had no prenatal care. This is the client's third pregnancy, and she says that her uterus never grew this big or this fast with the previous pregnancies. Based on the client's reason for seeking care, the nurse would collect additional data to rule out the presence of...placental abruption (abrupto placentae)

False

T/F A client reports bright red, painless vaginal bleeding during the 32nd week of pregnancy. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. One immediate care measure initiated is...assist the client in stirrups and perform a pelvic examination

False

T/F A client reports bright red, painless vaginal bleeding during the 32nd week of pregnancy. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. One immediate care measure initiated is...place the client on bed rest maintaining the supine position.

False

T/F A client who is diagnosed with septic pelvic thrombophlebitis is prescribed heparin therapy by the health care provider. One nursing assessment the nurse should prioritize to begin each nursing shift is...fluid status

False

T/F A home health care nurse is visiting a pregnant client with preeclampsia who is being managed at home. The nurse is reviewing the situations for which the client should contact the nurse. The nurse determines that the client demonstrates understanding when identifying one situation as needing to be reported as...increased urination

False

T/F A home health care nurse is visiting a pregnant client with preeclampsia who is being managed at home. The nurse is reviewing the situations for which the client should contact the nurse. The nurse determines that the client demonstrates understanding when identifying one situation as needing to be reported as...sinus headache

False

T/F A new mother is diagnosed with a venous thromboembolism in her left calf. One risk factor associated with this problem is...hypotension

False

T/F A new mother is diagnosed with a venous thromboembolism in her left calf. One risk factor associated with this problem is...maternal age greater than 30

False

T/F A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for postpartum infection base on...rupture of membranes for 16 hours

False

T/F A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify one sign as needing to be reported as...approximately eight wet diapers a day

False

T/F A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify one sign as needing to be reported as...general fussiness

False

T/F A nurse suspects the a pregnant client may be experiencing a placental abruption (abruptio placentae). One finding that would support this suspicion is...absence of pain

False

T/F 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. Other data needs to be collected in assessing this client for a DVT includes...note the capillary refill of the toes

False

T/F A postpartum woman is concerned about constipation following delivery. One factor that contributes to this problem is...intake of too many fluids

False

T/F A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. One finding that would lead the nurse to suspect that the woman is developing an infection is...decreased C-reactive protein levels

False

T/F A woman birthed her infant 24 hours ago by cesarean. One assessment finding that should be reported to the assigned nurse is...bleeding is noted on the abdominal dressing 2 x 5 cm in size

False

T/F A woman birthed her infant 24 hours ago by cesarean. One assessment finding that should be reported to the assigned nurse is...fundal height is one fingerbreadth below the umbilicus

False

T/F A woman birthed her infant 24 hours ago by cesarean. One assessment finding that should be reported to the assigned nurse is...the client's abdomen is mildly distended and bowel sounds are hypoactive

False

T/F During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. One finding would correlate with this suspicion is...the umbilical cord is stained bright red

False

T/F On parameter measured in determining an APGAR score is...blood pressure

False

T/F On parameter measured in determining an APGAR score is...oxygen saturation

False

T/F One characteristic of a newborn with fetal alcohol syndrome would include...hypocalcemia and hypokalemia

False

T/F One characteristic of a newborn with fetal alcohol syndrome would include...prominent cheekbones and LGA

False

T/F One finding the nurse should report to the health care provider for a postpartum client who delivered 12 hours ago is...episiotomy appears edematous

False

T/F One intervention the nurse would take to reduce the incidence of infection in a postpartum woman is...have the mother maintain a low activity level to allow the perineum to heal

False

T/F The nurse is monitoring a client at 36 weeks' gestation who is bleeding. The nurse is preparing to insert a Foley catheter. One explanation the nurse should provide the client regarding the need for a urinary catheter is..."We need to monitor the urine for the presence of blood."

False

T/F The nurse is orienting in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. One symptom the preceptor would describe to the new nurse as a sign of severe preeclampsia is...glycosuria

False

T/F The nurse is orienting in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. One symptom the preceptor would describe to the new nurse as a sign of severe preeclampsia is...seizure

False

T/F The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. One intervention the nurse would include is...preparing the woman for insertion of a feeding tube.

False

T/F The nurse is reviewing the notes for a newborn. One finding that would alert the nurse to further assess the newborn's respiratory status is...glucose level

False

T/F The nurse is reviewing the notes for a newborn. One finding that would alert the nurse to further assess the newborn's respiratory status is...heart rate

False

T/F The nurse is reviewing the notes for a newborn. One finding that would alert the nurse to further assess the newborn's respiratory status is...oxygen saturation

False

T/F The nurse performs a physical examination on a newborn 2 hours after birth. One finding that would indicate a need for a pediatric consultation is...intermittent episodes of apnea lasting less than 10 seconds each

False

T/F The nurse performs a physical examination on a newborn 2 hours after birth. One finding that would indicate a need for a pediatric consultation is...preauricular skin tag noted on left ear

False

T/F The nurse performs a physical examination on a newborn 2 hours after birth. One finding that would indicate a need for a pediatric consultation is...respiratory rate of 50 breaths per minute

False

T/F The nurse reviews the notes from the electronic health record of the newborn. One finding the nurse identifies that increases the newborn's risk for hypoglycemia is...gestational age

False

T/F The nurse reviews the notes from the electronic health record of the newborn. One finding the nurse identifies that increases the newborn's risk for hypoglycemia is...temperature

False

Which nursing measure is most effective in reducing newborn infections?

Maintain medical asepsis while providing care.

A nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion. The nurse determines that the teaching is successful when the group identifies which condition as the most common cause of first trimesters abortions?

Fetal genetic abnormalities

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?

Gently stroke the newborn's cheek.

In an infant who has hypothermia, what would be an appropriate nursing diagnosis?

Impaired tissue perfusion

What behaviors are expected during the taking in phase?

Increased dependency Emphasis on self Requires additional assistance A desire to review the birth experience

What behaviors are expecting during the letting go phase?

Independence Provides all infant care Emphasis on family as a whole Reassertion of relationship with partner Sexual intimacy resumes Resolution of individual roles

A client comes to the genitourinary clinic with very mild symptoms of pelvic organ prolapse (POP) that has just started in the last several days. What would be the treatment of choice for this client?

Kegel exercises

The nurse is caring for an Rh-negative nonimmunized client at 14 weeks' gestation. What information would the nurse provide to the client?

Obtain Rho(D) immune globulin at 28 weeks' gestation.

The LPN has reported that uterine massage is ineffective on a client. The nurse anticipates the health care provider will prescribe which medication to address this issue?

Oxytocin

A patient presents with polyhydramnios. AROM is performed and the fluid is clear and odorless. Fetal heart rate is 100 and shows an irregular sharp drop. What action should the RN take?

Perform a sterile vaginal exam

A newborn 3 day old shows a yellowish tinge from the face to mid-chest. What diagnosis is most likely?

Physiologic jaundice

What does lochia serosa look like?

Pinkish and watery

A vaginal exam is performed and the umbilical cord is seen protruding from the vagina. What is the initial intervention performed?

Place patient in Trendelenburg position.

Which intervention is helpful for the neonate experiencing drug withdrawal?

Place the isolette in a quiet area of the nursery.

A nurse is admitting a full-term pregnant patient presenting with bright red vaginal bleeding, intense abdominal pain. Her blood pressure on admission is 150/96 mm Hg, pulse of 109. which problem should the nurse suspect that the patient is likely experiencing?

Placental abruption

The RN is teaching a class about postpartum mood disorders. They describe a transient, self-limiting mood disorder that affects mothers after childbirth. It is determined the class has understood when they identify the disorder as what?

Postpartum blues

The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client?

Prepare the client for a cesarean birth.

T/F A nurse is caring for a client with cardiovascular disease who has just given birth. One nursing intervention the nurse would perform when caring for this client is...assess for edema and note any pitting

True

T/F A nurse is caring for a client with cardiovascular disease who has just given birth. One nursing intervention the nurse would perform when caring for this client is...assess for moist cough

True

T/F A nurse is caring for a newborn with hypoglycemia. One symptom of hypoglycemia the nurse should monitor for in the newborn is...lethargy

True

T/F A 32 weeks' gestation newborn in the neonatal intensive care is being assessed for hyperbilirubinemia. One diagnostic test the nurse would expect to be done is...blood type

True

T/F A 32 weeks' gestation newborn in the neonatal intensive care is being assessed for hyperbilirubinemia. One diagnostic test the nurse would expect to be done is...direct Coombs

True

T/F A client at 36 weeks' gestation experiences vaginal bleeding. One condition that might be the cause of the client's bleeding is...bloody show

True

T/F A client comes to the clinic reporting swelling in the hands and feet, blurred vision, a pounding headache and nausea and vomiting. The client had a positive pregnancy test 15 weeks ago, but has had no prenatal care. This is the client's third pregnancy, and she says that her uterus never grew this big or this fast with the previous pregnancies. Based on the client's reason for seeking care, the nurse would collect additional data to rule out the presence of...preeclampsia

True

T/F A client is experiencing postpartum hemorrhage shortly after the birth of the infant. One nursing intervention appropriate for this client is...begin uterine massage with both hands on the fundus of the uterus

True

T/F A client is experiencing postpartum hemorrhage shortly after the birth of the infant. One nursing intervention appropriate for this client is...encourage increased fluid intake

True

T/F A client is experiencing postpartum hemorrhage shortly after the birth of the infant. One nursing intervention appropriate for this client is...encouraging the client to breastfeed the infant, if she is breastfeeding

True

T/F A client reports bright red, painless vaginal bleeding during the 32nd week of pregnancy. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. One immediate care measure initiated is...determine the time the bleeding began and about how much blood has been lost

True

T/F A client reports bright red, painless vaginal bleeding during the 32nd week of pregnancy. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. One immediate care measure initiated is...obtain baseline vital signs and compare to those vital signs previously obtained

True

T/F A client who is diagnosed with septic pelvic thrombophlebitis is prescribed heparin therapy by the health care provider. One nursing assessment the nurse should prioritize to begin each nursing shift is...platelet count

True

T/F A home health care nurse is visiting a pregnant client with preeclampsia who is being managed at home. The nurse is reviewing the situations for which the client should contact the nurse. The nurse determines that the client demonstrates understanding when identifying one situation as needing to be reported as...blurred vision

True

T/F A home health care nurse is visiting a pregnant client with preeclampsia who is being managed at home. The nurse is reviewing the situations for which the client should contact the nurse. The nurse determines that the client demonstrates understanding when identifying one situation as needing to be reported as...dizziness

True

T/F A home health care nurse is visiting a pregnant client with preeclampsia who is being managed at home. The nurse is reviewing the situations for which the client should contact the nurse. The nurse determines that the client demonstrates understanding when identifying one situation as needing to be reported as...excessive heartburn

True

T/F A new mother delivered one week ago and is tearful, anxious, sad and has no appetite. She is diagnosed with postpartum blues. One factor that contributes to this problem is...discomfort

True

T/F A new mother delivered one week ago and is tearful, anxious, sad and has no appetite. She is diagnosed with postpartum blues. One factor that contributes to this problem is...disrupted sleep patterns

True

T/F A new mother delivered one week ago and is tearful, anxious, sad and has no appetite. She is diagnosed with postpartum blues. One factor that contributes to this problem is...fatigue

True

T/F A new mother is diagnosed with a venous thromboembolism in her left calf. One risk factor associated with this problem is...obesity

True

T/F A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify one sign as needing to be reported as...abdominal distension

True

T/F A nurse suspects the a pregnant client may be experiencing a placental abruption (abruptio placentae). One finding that would support this suspicion is...dark red vaginal bleeding

True

T/F 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. Other data needs to be collected in assessing this client for a DVT includes...feel the right calf for increased warmth

True

T/F A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. One finding that would lead the nurse to suspect that the woman is developing an infection is...abdominal tenderness

True

T/F A woman birthed her infant 24 hours ago by cesarean. One assessment finding that should be reported to the assigned nurse is...uterus feels boggy

True

T/F One finding the nurse should report to the health care provider for a postpartum client who delivered 12 hours ago is...fundal height level of one fingerbreadth above the umbilicus

True

T/F One finding the nurse should report to the health care provider for a postpartum client who delivered 12 hours ago is...temperature of 101.8°F (38.8°C)

True

T/F Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5 Ts tool will recognize one potential cause of postpartum hemorrhage as...tone

True

T/F The nurse is monitoring a client at 36 weeks' gestation who is bleeding. The nurse is preparing to insert a Foley catheter. One explanation the nurse should provide the client regarding the need for a urinary catheter is..."The amount of urine output is an indication of tissue perfusion."

True

T/F The nurse is orienting in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. One symptom the preceptor would describe to the new nurse as a sign of severe preeclampsia is...nondependent edema

True

T/F The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. One intervention the nurse would include is...administering antiemetic agents.

True

T/F The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. One intervention the nurse would include is...monitoring intake and output.

True

T/F The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. One intervention the nurse would include is...obtaining baseline blood electrolyte levels.

True

T/F The nurse is reviewing the notes for a newborn. One finding that would alert the nurse to further assess the newborn's respiratory status is...gestational age

True

T/F While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios. Information the nurse would use to support this suspicion is...reports of shortness of breath

True

Which body system is most vulnerable to infection during the postpartum period?

Urinary

During pregnancy a client's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the client eliminates the additional fluid volume they have been carrying. What is one way the client does this?

Urinary elimination

The nurse is caring for a multigravid who experienced a placental abruption 4 hours ago. For which potential situation will the nurse prioritize assessment?

Uterine atony

What is the most common cause of postpartum hemorrhage?

Uterine atony

Which of the following findings in a newborn would be considered normal? a. Passage of meconium within the first 24 hours b. Respiratory rate of 80 breaths/min c. Yellow skin tones at 10 hours after birth d. Bleeding from the umbilicus area

a. Passage of meconium within the first 24 hours

After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have a. intense back pain. b. frequent leg cramps. c. nausea and vomiting. d. a precipitous birth.

a. intense back pain

A woman who is Rh negative asks the nurse how many children she will be able to have before Rh incompatibility causes them to die in utero. The nurse's best response would be that:

as long as she receives Rho(D) immune globulin, there is no limit.

The nurse is instructing the postpartum client who plans to bottle-feed her newborn about measures to prevent breast engorgement when she is discharged. Which measure should the nurse include in the teaching plan? a. Decreasing her fluid intake for the first week at home b. Wearing a tight-fitting supportive bra 24 hours daily c. Take a diuretic to release the extra fluid in the breasts d. Manually express the milk that is accumulating

b. Wearing a tight-fitting supportive bra 24 hours daily

Immediately after childbirth in the recovery area, the nurse observes the mother's partner's fascination and interest in the new child. This behavior is often termed what? a. attachment. b. engrossment. c. bonding. d. temperament.

b. engrossment

The nurse would anticipate a cesarean birth for a client who has which active infection present at the onset of labor? a. Hepatitis b. Herpes simplex virus c. Toxoplasmosis d. Human papillomavirus

b. herpes simplex virus

The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to a. encourage ambulation every 30 minutes. b. provide pain relief measures. c. monitor the oxytocin infusion rate closely. d. prepare the woman for an amniotomy.

b. provide pain relief measures.

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 what? a. initial period of reactivity b. second period of reactivity c. decreased responsiveness period d. sleep period

b. second period of reactivity

A pregnant woman in her 39th week of pregnancy presents to the clinic with a vaginal infection. She tests positive for chlamydia. What would this disease make her infant at risk for?

blindness

The nurse is caring for a new infant and notes on assessment the newborn is small for gestational age and also has indications of intrauterine growth restriction. Which assessments should the nurse prioritize about the mother as a potential cause for the infant's condition?

blood glucose levels

A woman has been diagnosed as having gestational hypertension. Which symptom for this condition is the most typical?

blood pressure elevation

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation

In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman's behavior to be characterized in what way? a. Gaining self-confidence b. Adjusting to her new relationships c. Being passive and dependent d. Resuming control over her life

c. Being passive and dependent

After teaching a group of breastfeeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? a. Carbohydrates and fiber b. Fats and vitamins c. Calories and protein d. Iron-rich foods and minerals

c. Calories and protein

Which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head? a. Two soft spots palpated between the cranial bones b. A spongy area of edema outlined on the head c. Head circumference 32 cm, chest 34 cm d. Asymmetry of the head with overriding bones

c. Head circumference 32 cm, chest 34 cm

The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What findings would the nurse expect? a. Cream-colored lochia; uterus above the umbilicus b. Bright red lochia with clots; uterus two fingerbreadths below umbilicus c. Light pink or brown lochia; uterus four to five fingerbreadths below umbilicus d. Yellow, mucousy lochia; uterus at the level of the umbilicus

c. Light pink or brown lochia; uterus four to five fingerbreadths below umbilicus

What activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home?a. Punishing the older child for bedwetting behavior b. Sending the sibling to the grandparents' house c. Planning a daily "special time" for the older sibling d. Allowing the sibling to share a room with the infant

c. Planning a daily "special time" for the older sibling

A client who is in active labor and whose cervix had dilated to 6 cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of what? a. hypertonic labor b. precipitate labor c. hypotonic labor d. dysfunctional labor

c. hypotonic labor

The nurse encourages a female client with human papillomavirus (HPV) to receive continued follow-up care because she is at risk for what>?

cervical cancer.

The nurse is explaining to a postpartum woman 48 hours after childbirth that the afterpains she is experiencing can be the result of which factor? a. Abdominal cramping as a sign of endometriosis b. A small infant weighing less than 8 lb c. Pregnancies that were too closely spaced d. Contractions of the uterus after birth

d. Contractions of the uterus after birth

A newborn with tracheoesophageal fistula is likely to present with which assessment finding? a. Subnormal temperature b. Absent Moro reflex c. Inability to swallow d. Drooling from mouth

d. Drooling from mouth

Which of these activities would best help the postpartum nurse provide culturally sensitive care for the childbearing family? a. Taking a transcultural course b. Caring for only families of the nurse's cultural origin c. Teaching Western beliefs to culturally diverse families d. Educating themselves about diverse cultural practices

d. Educating themselves about diverse cultural practices

A new mother gave birth 12 hours ago. Because this is her first child, which goal planned by the nurse is most appropriate? a. Early discharge for the mother and newborn b. Rapid transition into the role of being a parent/caregiver d. Minimal need for expression of feelings now d. Effective education of both parents before discharge

d. Effective education of both parents before discharge

Which immunization is most commonly received by newborns before hospital discharge? a. Pneumococcus b. Varicella c. Hepatitis A d. Hepatitis B

d. Hepatitis B

When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as what? a. cervical insufficiency b. contracted pelvis c. maternal disproportion d. fetopelvic disproportion

d. fetopelvic disproportion

Which finding might be seen in a neonate suspected of having an infection?

decreased temperature

The nurse notices while holding a 1-day-old infant upright that the baby has a significantly indented anterior fontanel (fontanelle). She immediately brings it to the attention of the health care provider. What does this finding indicate?

dehydration

The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from:

developing Rh sensitivity

A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour after birth?

every 15 minutes

A nurse is conducting a class for expectant parents about newborns and the changes that they experience after birth. The nurse discusses the neonatal period, describing it as which time frame?

first 28 days of life

A client is scheduled for cryosurgery to remove some abnormal tissue on the cervix. The nurse teaches the client about this treatment, explaining that the tissue will be removed by which method?

freezing

The nurse is caring for a 14-year-old girl who fears she might have a sexually transmitted infection (STI). What would the nurse expect to assess if the adolescent has trichomoniasis?

green vaginal discharge

A nurse informs a pregnant woman with cardiac disease that she will need two rest periods each day and a full night's sleep. The nurse further instructs the client that which position for this rest is best?

left lateral recumbent

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

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

lochia rubra

What would be the physiologic basis for a placenta previa?

low placental implantation

A 58-year-old client comes to the clinic for evaluation. After obtaining the client's history, the nurse suspects endometrial cancer. Which information would lead the nurse to this suspicion?

onset of painless, bright red postmenopausal bleeding

A 40-year-old client arrives at the community health center experiencing a strange, dragging feeling in the vagina. She stated that "at times it feels as if there is a lump" there as well. Which condition do these symptoms indicate?

pelvic organ prolapse

During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?

peribottle and warm water

The nurse is assessing a woman with class III heart disease who is in for a prenatal visit. What would be the first recognizable sign that this client is in heart failure?

persistent rales in the bases of the lungs

A nursing instructor identifies which factor as increasing the chances of infection when coupled with prolonged labor?

premature rupture of membranes

A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating?

preterm labor

A client who had a cesarean birth of twins 6 hours ago reports shortness of breath and pain in the right calf. What complication should the nurse expect?

pulmonary embolism

Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?

redness in lower legs

A pregnant woman in her second trimester comes to the prenatal clinic for a routine visit. She reports that she has a new kitten. The nurse would have the woman evaluated for which infection?

toxoplasmosis

A nurse is speaking to a local women's group about the various types of cancer affecting the female reproductive tract. The nurse explains that ovarian cancer is the leading cause of death from gynecologic malignancies based on the understanding what about this type of cancer?

typically manifests with vague symptoms resulting in late diagnosis.

A client in active labor with a history of two previous cesarean births is being monitored frequently as they try to have a vaginal birth. Suddenly, the client grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes the client's blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication?

uterine rupture

A nurse is assessing a 20-year-old female. Which data finding taken during the history would indicate endometrial cancer?

vaginal bleeding that is painless and abnormal

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

vision

An elderly woman is seen in the clinic reporting a lesion on her labia majora and states that she has experienced some bleeding and itching as well. She states that this has been going on for approximately three months. She tells the nurse that she has not been to a health care provider in over 10 years. What diagnosis would the nurse expect the primary care provider to make?

vulvar cancer