OB Exam 3 prep u questions

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?

0.5 to 1 mL/kg/h

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 female in her mid-20s who appears pregnant

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."

A nurse is teaching a newborn's parents how to change a diaper correctly. Which statement by the parents best demonstrates understanding of what they have been taught?

"We will fold down the front of her diaper under the cord until it falls off."

What percentage of neonates require some type of assistance to transition to extrauterine life?

10%

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

7 to 10.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein's pearls

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?

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

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

fetal heart tones. When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?

head larger than body

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?

perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?

20th

How long is the neonatal period for a newborn?

28 The neonatal period is the first 28 days of life. pg. 564

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 mL whole blood Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia. p 837

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room.

The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?

Her blood pressure is below 140/90 mm Hg. Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

The nurse is assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would the nurse apply to the surgical area?

Petrolatum gauze dressing

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

apnea

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?

lack of pleasure Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed, cry a lot, exhibit a lack of energy and motivation, experience a lack of pleasure, changes in appetite, sleep, or weight, withdraw from friends and family, feel negatively toward her baby, or shows lack of interest in her baby

When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse interprets this finding as:

lanugo

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance should the nurse identify as the cause of afterpains?

oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin which causes lactation.

Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications?

weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions?

when the heart rate is less than 60 beats per minute

A preterm infant born at 32 weeks gestation is being started on formula. When planning care, the nurse anticipates that which formula type is best?

A 24 cal/oz infant formula.

A placenta succenturiate is a placenta in which the cord is inserted marginally rather than centrally. a) False b) True

a) False Rationale: In a battledore placenta, the cord is inserted marginally rather than centrally. A placenta succenturiata is a placenta that has one or more accessory lobes connected to the main placenta by blood vessels.

The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient?

22 calories per ounce

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

500 additional calories per day The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.

A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:

term

A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:

term. A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is born between 34 and 37 weeks' gestation.

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

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization The nurse should assess infertility treatment as a contributor to increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages. pg 758

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot

The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long?

the first 6 months

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?

third-degree laceration 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 mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:

this is a normal finding. Newborn stools typically pass through a pattern of meconium, green transitional, and then yellow. pg 577

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often?

two or three times per week

When assessing the newborn's umbilical cord, what should the nurse expect to find?

two smaller arteries and one larger vein When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.

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

urinary elimination In the early postpartum period, the woman eliminates the additional fluid volume that is present during the pregnancy via the skin and urinary tract and through blood loss.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. uterine infection hydramnios early ambulation empty bladder breastfeeding prolonged labor

uterine infection hydramnios prolonged labor Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breast-feeding, early ambulation, and an empty bladder would facilitate uterine involution.

A primigravida at 28 weeks' gestation comes to the clinic for a check-up. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with premature birth would the nurse discuss with the client? Select all that apply.

uterine or cervical abnormalities current multiple gestation pregnancy history of previous preterm birth The top three risk factors for premature birth are history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities.

A woman in labor is receiving oxytocin. Which effect would the nurse need to be alert for potentially occurring?

water intoxication Oxytocin can lead to water intoxication and can cause hypotension. Uterine hypertonicity is a possible adverse effect of oxytocin administration. Oxytocin does not cross the placental barrier, and no fetal problems have been observed.

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

within the first 2 to 4 hours, when the newborn reaches the nursery

A nursing supervisor calls a nurse into his office to talk to the employee. The supervisor asks the nurse if she is wearing artificial nails and the nurse responds that she is. The supervisor tells her that she must remove them for what reason?

Artificial nails harbor bacteria and increase the spread of infection.

Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn?

Assess for decrease in urinary output.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema. Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count. A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin.

A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem?

Auscultate breath sounds.

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?

Bathe the newborn thoroughly

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?

Both the mother and infant have identification bands that need to match.

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature. Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also is associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority. pg 850

A nurse is performing a detailed assessment of a female newborn. Which observations indicate normal findings? Select all that apply.

Mongolian spots swollen genitals short, creased neck

A preterm infant is receiving indomethacin. What is a priority assessment following administration of indomethacin? Select all that apply.

Monitor urine output. Observe for bleeding.

The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.

Progress of labor deviates from normal. Labor is slow. Dystocia is said to exist when the progress of labor deviates from normal and is slow.

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how the child is turned.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

RDS is caused by a lack of alveolar surfactant.

A group of expectant parents are touring the labor and birthing unit of a local hospital as part of their prenatal classes. When explaining the procedures used to prevent infant abduction, the nurse is less likely to point out which common factor about the abductor?

Targets a specific infant

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?

The infant is experiencing moderate difficulty in adjusting to extrauterine life.

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Hypertonic contractions cause uterine cell anoxia, which is painful.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth. Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants. p.858

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?

The newborn will experience no bleeding episodes lasting more than 5 minutes.

Which nurse is practicing in a manner to reduce or eliminate pain in a newborn?

The nurse who suggests to the primary care provider to change ordered IM antibiotics to IV.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded. The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation. pg 835

The nurse is assessing an infant's reflexes. While eliciting a rooting reflex, the infant strongly sucks on the nurse's finger. How does the nurse interpret this finding?

The rooting reflex was tested incorrectly. Gently stroking the newborn's cheek brings out the rooting reflex. The newborn would demonstrate this reflex by turning toward the touch with an open mouth. This infant demonstrates a positive suck reflex but does not display the rooting reflex because the test was performed incorrectly. pg 580

The nurse is giving a newborn his first bath. What should the nurse prioritize?

Wash off all traces of blood and leave the vernix in place.

A nurse is caring for a pregnant client whose fetus has been diagnosed with macrosomia. When reviewing the client's history, which of the following would the nurse expect to find? a) Gestational diabetes b) Maternal rickets c) Small body size of mother d) Pre-term pregnancy

a) Gestational diabetes Rationale: Macrosomia usually results from uncontrolled gestational diabetes, genetic problems, multiparity, or post-term pregnancy. Pre-term pregnancy, small body size of mother, and maternal rickets are not associated with macrosomia. Small body size and maternal rickets are associated with pelvic contraction at the inlet.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? a) Symptoms include fever, chills, malaise, and localized breast tenderness b) The most common pathogen is group A beta-hemolytic streptococci c) Mastitis usually develops in both breasts of a breast-feeding client d) A breast abscess is a common complication of mastitis

a)Symptoms include fever, chills, malaise, and localized breast tenderness Explanation: Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?

apnea Preterm newborns are at a greater risk for cold stress than term or postterm newborns. Cold stress can cause hypoglycemia, increased respiratory distress and apnea, and metabolic acidosis. Preterm infants lack the ability to shiver in response to cold stress. pg 573

Retention of placental fragments commonly leads to hypertension. a) False b) True

b) True

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?

convection Convection refers to loss of heat from the newborn's body to the cooler surrounding air.

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness

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 cyanosis jitteriness

The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successfull after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?

more than two episodes of diarrhea in one day

A nurse is caring for a client in the postpartum period. The client is emotionally sensitive, feels a sense of failure, and attempts to hurt herself and the baby. The nurse understands that the client is exhibiting symptoms of which condition?

postpartum depression The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant?

rocking and massaging

When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment?

rooting

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best?

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker."

A client gave birth vaginally 2 days prior and wishes to prevent getting pregnant again. She asks the nurse when she will need to begin birth control measures. How should the nurse respond?

"Ovulation may return as soon as 3 weeks after birth." Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than six months after birth.

The parents of a newborn baby boy ask the nurse about circumcising their son. They are undecided as to what to do. Which response by the nurse is best?

"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure."

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?

Clustering care and activities

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 6 to 12 hours

On an Apgar evaluation, how is reflex irritability tested?

flicking the soles of the feet and observing the response

A nurse is conducting a physical examination of a newborn. The nurse documents which finding as within normal parameters? Select all that apply.

length of 54 cm weight of 3,300 grams temperature of 98.6° F (37° C)

Which statement by the parents is evidence of meeting the desired outcome for a nursing diagnosis of impaired parenting?

"I'm so happy to hold you; I think you like it too."

How can new parents aid their newborn to develop trust so the infant can become more organized in the responses to his or her environment?

Be attentive to the basic needs of the infant and be consistent.

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?

Using a bulb syringe, suction the mouth then the nose.

Which assessment finding by the nurse would indicate that a neonate is being comforted?

increased oxygen saturation

The parents of a newborn are concerned that something is wrong with their newborn's eyesight. What should the nurse instruct the parents as being an expected finding in the newborn?

Follows a light to the midline

The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply.

Gonorrhea Chlamydia

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?

"I can't wait for these stretch marks to disappear after I give birth." Stretch marks gradually fade to silvery lines but do not disappear completely. As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen, face, and nipples gradually fades.

A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?

"Be sure to change your pajamas to prevent you from chilling." The nurse should encourage the client to change her pajamas to prevent chilling and reassure the client that it is normal to have postpartal diaphoresis. Drinking cold fluids at night will not prevent postpartum diaphoresis.

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

"A late preterm newborn may have more clinical problems compared with full-term newborns."

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 give him vitamin D supplements daily for the first 2 months of life."

After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment?

"I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months. Breastfeeding is not a totally reliable method of contraception unless the mother exclusively breastfeeds, has had no menstrual period since giving birth, and whose infant is younger than 6 months old; however, ovulation may occur before menstruation.

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?

"If our baby turns red in the face and strains to have a stool that means she is constipated."

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?

"We'll hold off on feeding him for a while because he might be too full."

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist.

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?

0.5 to 1 mL/kg/h Minimal enteral feeding is used to prepare the preterm newborn's gut to overcome the many feeding difficulties associated with gastrointestinal immaturity. It involves the introduction of small amounts, usually 0.5 to 1 mL/kg/h, of enteral feeding to induce surges in gut hormones pg 842

The nurse is assigned to a client on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus?

1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? At the symphysis pubis 1 cm above the umbilicus At level of umbilicus 1 cm below the umbilicus

1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day?

650 Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day.

A new mother asks the nurse what her neonate can actually see. When responding to the mother, the nurse integrates knowledge that newborns typically can focus on objects at which distance?

8 to 10 inches (20 to 25 cm) Newborns have ability to focus only on close objects (8 to 10 inches away [20 to 25 cm]) with a visual acuity of 20/140; they can track objects in midline or beyond (90 inches [229 cm]). This is the least mature sense at birth.

In a class teaching new parents basic information on how to care for their new infant, the nurse should suggest that the parents plan to use how many diapers on a daily basis?

10

New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age?

10%

What percentage of neonates require some type of assistance to transition to extrauterine life?

10% Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at 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 17-29 pounds 10-15 pounds 15-22 pounds

17-29 pounds 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 explaining to the parents about the various laboratory tests which will be conducted on their newborn. The nurse should point out that testing for phenylketonuria will be conducted in which time frame?

2 to 3 days after birth.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding

In which time period would the nurse expect a client who has given birth to twins to experience late postpartum hemorrhage?

24 hours to 12 weeks after birth Delayed or late postpartum hemorrhages occur more than 24 hours but less than 12 weeks postpartum. Immediate, early, or primary postpartum hemorrhages occur within 24 hours of birth.

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's suspicion?

30 mg/dL

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?

37.0° C (98.6° F) On average a newborn's temperature ranges from 36.5° C to 37.5° C (97.9° F to 99.7° F).

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500 mL Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

The nursery head nurse is conducting an in-service on prevention of hypoglycemia to her staff. What information would she share with this group? Select all that apply.

Encourage breast-feeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns.

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 mL whole blood

A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?

40 to 60 breaths per minute

The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women?

85% Postpartum blues, or mild depression during the first 10 days after giving birth, affects up to 85% of women who give birth. More intense depression during this period is referred to as postpartum depression, which affects approximately 10% to 15% of postpartum clients. Postpartum depression can be severe with negative implications for maternal and neonatal well-being.

What supplies would the nursery nurse collect in preparation of doing a bath on a newborn infant? Select all that apply.

A washcloth Warm tub of water Thermometer

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule?

Cervix dilates 1 cm per hour. A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation. If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out.

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.

Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants. pg 850

It is discovered that a new mother has developed a puerperal infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?

Client's temperature remains below 100.4° F or 38° C orally. As fever would accompany a puerperal infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to puerperal infection as does the reduced temperature.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next

Educate the client on how to perform Kegel exercises. Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

A mother of a 32-week-gestation neonate is encouraged to perform kangaroo care in the neonatal intensive care unit. What would best correlate with this suggestion?

Breastfeeding attempts will be enhanced.

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?

Call her caregiver if lochia moves from serosa to rubra. Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4° F (38° C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant?

Blood flows from the aorta to the pulmonary artery.

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Check blood glucose

Before calling the primary care provider to notify him or her of a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder. A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

On inspecting a newborn's abdomen, which finding would you note as abnormal?

Clear drainage at the base of the umbilical cord

A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply?

Empty the breasts frequently. The nurse should tell the client to frequently empty the breasts to improve milk supply. Encouraging cold baths and applying ice on the breasts are recommended to relieve engorgement in nonbreastfeeding clients. Kegel exercises are encouraged to promote pelvic floor tone.

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?

Cooperation by the parents with the hospital policies

A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?

Ensure that the infant is kept warm.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

Epstein's pearls.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal?

Escherichia coli E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of metritis, but some species of Klebsiella may cause urinary tract infections.

A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? Encourage the mother to breast-feed to help relax the uterus. Tell her that you will notify the doctor of the unusual pain and see what he wants to do. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Recommend that the client ambulate more to help relieve the pain.

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Afterpains occur most commonly in multipara mothers and occur when the uterus contracts and relaxes at intervals. Breast-feeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the doctor.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Feed the baby at least every two or three hours. Apply cold compresses to the breasts. Provide the infant oral nystatin. Dry the nipples following feedings.

Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

Fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

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?

General questions about different aspects of newborn care

The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record?

Head one fourth of total length

A patient who has just given birth to her first baby asks the nurse for help with breast-feeding. Which nursing diagnosis would be the most appropriate for the patient at this time?

Health-seeking behaviors

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Injecting the medication into the vastus lateralis

The nurse has been doing bag and mask resuscitation for over 2 minutes. What additional intervention will the nurse initiate?

Insert an orogastric tube.

A newborn is identifies as extremely low birth weight placing the newborn's weight at which level?

Less than 1,000 g.

At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia?

Maintain adequate respirations.

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?

Massage the boggy fundus until it is firm. The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.

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. Tachycardia and a boggy fundus in the postpartum woman indicate excessive blood loss. The nurse would massage the fundus to promote uterine involution. It is not priority to notify the healthcare provider, assess blood pressure, or change the peri-pad at this time.

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?

McRobert's maneuver The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases. pg 759

The nurse in the newborn nursery is placing a 30-minute-old newborn on a radiant warmer for thermoregulation. Where should she apply the temperature probe to be most accurate?

Over the liver on the abdomen

The nurse caring for a small for gestational age newborn in the specialcare nursery. What characteristics are commonly documented? Select all that apply.

Poor skin turgor Sparse or absent hair Diminished muscle tissue

When planning the care for a small for gestational age (SGA) newborn, which action would the nurse determine as a priority?

Preventing hypoglycemia with early feedings

The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?

Retracting the foreskin over the glans to assess for secretions

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing. Certain risk factors contribute to the development of mastitis. These include: inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

Why should a nurse monitor a newborn after cesarean birth more closely than after a vaginal birth?

The baby will have more fluid in its lungs, making respiratory adaptation more challenging. During a vaginal birth the infant is squeezed by the uterine contractions. The infant who is born via cesarean birth without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise, so there is a need to more closely assess a newborn after birth pg 569

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded.

What should the nurse expect for a full-term newborn's weight during the first few days of life?

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life. pg 576

A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which tests should the student include? Select all that apply.

U/A amniotic fluid analysis CBC Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis. pg 772

Labor dystocia is an abnormally progression of labor. It is the most common cause of primary caesarian delivery. When is it most common for labor dystocia to occur? a) Second stage of labor b) Third stage of labor c) Fourth stage of labor d) First stage of labor

a) Second stage of labor Rationale: Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

Before calling the physician to notify him or her of a slow progression or an arrest of labor several assessments need to be made. What other maternal assessment do you need to make prior to calling the physician? a) Check for a full bladder. b) Make sure the epidural medication is turned down. c) Make sure the patient is lying on their left side. d) Assess vital signs every 30 minutes.

a) Check for a full bladder. Rationale: Remember that a full bladder can interfere with the progress of labor. So be sure that the patient has emptied her bladder.

You assess that the fetus of a woman is in an occiput posterior position. Which of the following identifies the way you would expect her labor to differ from others? a) Experience of additional back pain. b) Necessity for vacuum extraction for delivery. c) Need to have the baby manually rotated. d) Shorter dilatational stage of labor.

a) Experience of additional back pain. Rationale: Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction delivery.

Tocolytic therapy will help to prevent preterm birth. a) False b) True

a) False Rationale: Tocolytic therapy does not typically prevent preterm birth, but instead it may delay it.

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile A newborn whose weight is above the 90th percentile on growth charts is defined as large-for-gestational-age.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask. An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used with hypertonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position. pg 759

A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of:

aging placenta.

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?

amniotic fluid embolism With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. pg 789

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

Which newborn neuromuscular system adaptation would the nurse not expect to find?

an extrusion reflex at 9 months of age

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication?

atelectasis

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time? a) < 5 hours b) < 3 hours c) < 8 hours d) < 4 hours

b) < 3 hours Rationale: Precipitous labor is completed in less than 3 hours.

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus. a) False b) True

b) True Rationale: none

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

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:

chest rises with each bag compression.

The nurse is admitting the patient in labor. The physician determines that the fetus is in a transverse lie and not responsive to Leopold's maneuvers. What intervention should the nurse provide for the patient? a) Prepare for a precipitous vaginal birth. b) Prepare to assist the physician with an amniotomy. c) Administer an analgesic to the patient. d) Prepare the patient for a Cesarean section.

d) Prepare the patient for a Cesarean section. Rationale: If a transverse lie persists, the fetus cannot deliver vaginally. The most common method the practitioner uses to diagnose fetal malpresentation is Leopold's maneuvers followed by ultrasound. Sometimes the practitioner notes transverse lie by looking at the contour of the abdomen, which tends to be in the shape of a football, wider side to side than top to bottom.

Which of the following describes why hypertonic contractions tend to become very painful? a) More than one contraction may begin at the same time, as receptor points in the myometrium act independently of each other. b) There is an increase in the length of labor because so many contractions are needed to achieve cervical dilation. c) The number of uterine contractions is very low or infrequent. d) The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells.

d) The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Rationale: Hypertonic contractions cause uterine cell anoxia, which is painful.

After an hour of administering oxytocin intravenously, you assess a woman's contractions to be 80 seconds in length. Your first action would be to a) continue to monitor contraction duration every 2 hours. b) slow the infusion to under 10 gtt per minute. c) increase the flow rate of the main line infusion. d) discontinue the oxytocin infusion.

d) discontinue the oxytocin infusion. Rationale: If uterine contractions lengthen beyond 70 seconds, there is apt to be an interference with fetal circulation. Discontinuing the infusion allows contractions to shorten in length and allow fetal nourishment.

The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. When reviewing maternal history, the nurse would interpret which factors as placing a newborn at risk for being LGA? Select all that apply.

diabetes mellitus multiparity history of postdates gestation

Assessment of a newborn reveals microcephaly. The nurse recognizes that this newborn may also have which complications? Select all that apply.

epilepsy cerebral palsy hearing disorders

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply.

expiratory grunting nasal flaring retractions tachypnea

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 The neonatal period is defined as the first 28 days of life. During this time period numerous physiologic changes occur as the infant adapts to the new environment

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?

first 30 to 60 minutes Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client?

fluid overload The possibility of fluid overload is increased and must be considered by a nurse when administering IV therapy to a newborn. IV therapy does not significantly increase heart rate or change blood pressure, as well as the level of consciousness, unless fluid overload occurs

When examining a newborn's eyes, the nurse would expect which assessment?

follows a light to the midline

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels When assessing the fluid status of a preterm newborn, the nurse palpates the fontanels. Sunken fontanels suggest dehydration; bulging fontanels suggest overhydration

An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?

hydrocephalus

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?

identical The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).

An infant that is diagnosed with meconium aspiration displays which symptom?

intercostal and substernal retractions

The process by which the reproductive organs return to the nonpregnant size and function is termed what?

involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition?

long-term obesity Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth

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 severe varicose veins preeclampsia Risk factors associated with thromboembolism include oral contraceptive use, multiparity, age over 35 years, severe varicose veins, and preeclampsia.

A nursing student correctly identifies the causes of labor dysfunction to include which factors? Select all that apply.

problems with the uterus problems with the fetus Labor dysfunction can occur because of problems with the uterus or fetus. Although the others might affect the type of prenatal care a woman receives, they do not directly affect her process of labor

A newborn in the nursery has a temperature of 97.4° F (36.3° C). What may happen first, if the infant continues to be cold stressed?

respiratory distress An infant who has an episode of cold stress is as risk for distress in the respiratory system. The infant needs to be warmed and monitored. If the infant is not warmed then hypoglycemia, seizures, and cardiovascular distress can occur, but they will not happen before the infant has respiratory distress.

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply.

rounded mass over symphysis pubis dullness on percussion over symphysis pubis fundus boggy to the right of the umbilicus If the bladder is distended, the nurse would most likely palpate a rounded mass at the the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4 degrees F (38 degrees C), infection is suggested.

Following resuscitation, a 4-pound infant is admitted to the NICU. The nurse would initiate enteral feedings based on which assessment?

stabilized respiratory effort

A pregnant woman has just presented to the emergency department with various reports and in distress. Which finding would lead the nurse to suspect that she is experiencing an amniotic fluid embolism? Select all that apply.

sudden onset of respiratory distress hypotension tachycardia The woman with an amniotic fluid embolism commonly reports difficulty breathing. Other signs include hypotension, tachycardia, cyanosis, seizures, coagulation difficulties, and uterine atony with subsequent hemorrhage. A sudden onset of fetal distress and acute continuous abdominal pain is associated with uterine rupture

A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?

the pressure the nurse uses when the hand squeezes against the bag

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-hold phase 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.

The nurse is assessing a postterm newborn. Which finding would the nurse be least likely to assess?

thick umbilical cord

Which complication is most likely responsible for a late postpartum hemorrhage?

uterine subinvolution Late postpartum bleeding is usually the result of subinvolution of the uterus. Retained products of conception or infection commonly cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may have an immediate postpartum hemorrhage if the deficiency is not corrected at the time of birth.

The nurse determines a newborn is small-for-gestational age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?

within one hour

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" "Let me show you how to calm him down. I've been doing this for many years." "You would probably be more successful if you wrapped him in on a warm blanket." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness. When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems. pg 793

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority?

Assign a female nurse to care for her. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Nurses give the daily bath for newborns of some Japanese-American women. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? Assist the woman into the shower, and have her run cold water over her breasts. Assist the woman in placing ice packs on her breasts. Explain to the woman that she should breastfeed because she is producing so much milk. Ask if she wants a breast pump to empty her breasts.

Assist the woman in placing ice packs on her breasts. If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production.

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is:

At risk for postpartum depression due to inadequate rest. This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time.

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle. The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia. pg 840

The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?

Begin supervised feedings for the newborn.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize?

Blood sugar 42 mg/dL

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question?

Take an oral contraceptive daily. When caring for a client with DVT, the nurse should instruct the client to avoid using oral contraceptives. Cigarette smoking, use of oral contraceptives, sedentary lifestyle, and obesity increase the risk for developing DVT. The nurse should encourage the client with DVT to wear compression stockings. The nurse should instruct the client to avoid using products containing aspirin when caring for clients with bleeding, but not for clients with DVT. Prolonged rest periods should be avoided. Prolonged rest involves staying motionless; this could lead to venous stasis, which needs to be avoided in cases of DVT.

A nurse is caring for the client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. Which should the nurse do next?

Tell the client to take an NSAID orally. The nurse should explain to the client that the afterpains are due to oxytocin released by the sucking reflex, which strengthens uterine contractions. An NSAID such as ibuprofen will decrease the discomfort from the afterpains. The client should not discontinue breastfeeding as this could decrease her milk supply. A warm shower may help relax the client; however, the NSAID would be more appropriate at this time.

Which of the following instructions would the nurse include in the teaching plan for a postpartum woman with mastitis? a)"Limit the amount of fluid you drink so your breasts don't get much fuller." b)"Stop breast-feeding until the pain and swelling subside." c)"Try applying warm compresses to your breasts to encourage the milk to be released." d)"You'll need to take this medication to stop the milk from being produced."

c)"Try applying warm compresses to your breasts to encourage the milk to be released." Explanation: Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breast-feeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present.

During a home visit, a new mother is concerned that, after three meconium stools, her newborn has had a bright green stool. What should the nurse explain to the mother?

This is a normal finding

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5T's tool will recognize which of the following as being a potential cause of postpartum hemorrhage? (Select all that apply.) a)Technique of delivery b)Time c)Thrombin d)Tone e)Tissue

c)Thrombin d)Tone e)Tissue Explanation: A helpful way to remember the causes of postpartum hemorrhage is by using the 5 T's: tone; tissue; trauma; thrombin; and traction.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? To monitor the mother's blood pressure to note any elevations To check for postpartum hemorrhage To determine if the mother's milk is coming in To answer questions the new parents may have

To check for postpartum hemorrhage If a new mother is going to hemorrhage, it will usually occur within the first hour following delivery. Therefore, the nurse checks on the client every 15 minutes, noting fundal firmness and position, amount and character of lochia and checking for bladder distension. There are no anticipated elevations in the mother's blood pressure, nor should the mother's milk come in this early.

The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?

To detect rebound hypoglycemia

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn?

Toes fan out when sole of foot is stroked.

The nurse is assisting with the birth of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to emerge, but instead of continuing to emerge, it retracts into the vagina. What should the nurse try first?

Use McRobert's maneuver. This intervention is used with a large baby who may have shoulder dystocia and require assistance. The legs are sharply flexed, by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli's maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is out of the province of the LVN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?

Use the sealed and chilled milk within 24 hours.

The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases?

Creases on two-thirds of the foot

A nursing instructor is conducting a class on the topic of circumcision. The instructor determines the class needs more education when they choose which factor as an advantage for having a circumcision?

Decreases risks of skin dehiscence, adhesions, and urethral fistulas

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. 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.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? The size of her infant Her bladder for distension Her hematocrit Her episiotomy

Her bladder for distension Bladder distension can cause the uterus to not contract effectively following delivery and displace to the side. This is easily checked and should be the first assessment done for a client whose uterus is not contracting as expected.

What is the best rationale for trying to decrease the incidence of cold stress in the neonate?

If the neonate becomes cold stressed, it will eventually develop respiratory distress If cold stressed the infant eventually will develop respiratory distress; oxygen requirements rise, even before noting a change in temperature, glucose use increases, acids are released into the bloodstream and surfactant production decreases bringing on metabolic acidosis. A flexed position, not an extended position keeps the neonate warm.

The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose the best reason to prevent cold stress?

If the neonate becomes cold stressed, it will eventually develop respiratory distress.

While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin?

IgA The newborn largely depends on three immunoglobulins for defense: IgG, IgA, and IgM. A major source of IgA is human breast milk, so breastfeeding is believed to have significant immunologic advantages over formula feeding. IgG is the only immunoglobulin that crosses the placenta.

A nurse is explaining the benefits of breastfeeding to a client who has just given birth. Which statement correctly explains the benefits of breastfeeding to this mother?

Immunoglobulin IgA in breast milk boosts a newborn's immune system. Breast milk is a major source of IgA, so breastfeeding is believed to have significant immunologic advantages over formula feeding. Breastfeeding does not provide more iron or calcium to the infant, maternal breast size does not increase, and most breastfed infants gain weight faster the first 2 months and then weight gain slows down.

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

Impaired tissue perfusion

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

A newborn infant at 36 hours of age is jaundiced. The mother is breast-feeding. What intervention is appropriate to increase the excretion of bilirubin?

Instruct the mom to feed every two to three hours.

The nursing instructor is leading a discussion on the physical changes to a woman's body after delivery of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs? Evolution Involution Decrement Progression

Involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?

It is a normal skin finding in a newborn.

The nurse is preparing to talk to a group of pregnant women about elective induction and why it is not highly recommended. Which statements should she include in her presentation? Select all that apply

It significantly increases the risk of cesarean birth. It significantly increases instrumented birth. It significantly increases the use of epidural analgesia. It significantly increases the admissions to the neonatal ICU. Evidence is compelling that elective induction of labor significantly increases the risk of cesarean birth, instrumented birth, use of epidural analgesia, and neonatal ICU admissions. Increased birth weight is not a factor. pg 776

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be srue to include in the presentation? Select all that apply.

Jitteriness Lethargy Seizures

What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord?

Keep it dry.

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action?

Keep the communication lines open. Failing to keep the lines of communication open with a bereaved client and her family closes off some of the channels to recovery and healing. Staff members that avoid dealing with the situation may imply that the problem will go away. As a result the family's needs go unrecognized, and they may feel isolated. The parents should be allowed to spend as much time as they need with the infant as it will help make the situation more real, help them in the grieving process, and allow them to say goodbye. pg 784

To maintain a sufficient fluid intake in a 3-month-old infant, the nurse should make which suggestions to the infant's mother?

Keeping track of the number of wet diapers/day is a good way of knowing the infant is getting enough fluid. The infant will need about 150-200 mL/kg of fluid intake/day. If the breast fed infant is having sufficient wet diapers, she is getting enough fluid.

A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone?

Kegel exercises The nurse should recommend that the client practice Kegel exercises to improve pelvic floor tone, strengthen the perineal muscles, and promote healing. Sitz baths are useful in promoting local comfort in a client who had an episiotomy during the birth. Abdominal crunches would not be advised during the initial postpartum period and would not help tone the pelvic floor as much as Kegal exercises.

A nurse is teaching a 42-week nulliparous pregnant woman about labor induction which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction?

Leopold's maneuver Before labor induction is started, fetal maturity (dating, ultrasound, amniotic fluid studies) and cervical readiness (vaginal examination, Bishop scoring) must be assessed. Both need to be favorable for a successful induction. Leopold's maneuver is a technique for determining the position of the fetus as it moves through the labor process.

What should the nurse consider when checking results of blood work done on a newborn?

Leukocytosis is usually present. 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.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100.8° F (38.2° C). Which action would be most appropriate for the nurse to take?

Notify the health care provider about this elevation; this finding reflects infection. A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A hematoma would not necessarily be a cause for an elevated temperature. Cultures may be warranted after notifying the health care provider. A temperature of 100.4° F or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor.

The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? Place an ice pack. Notify a primary care provider. Apply a warm washcloth. Put on a witch hazel pad.

Place an ice pack. The labia and perineum may be edematous after birth and bruised; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the primary care provider. Notifying a care provider is not necessary at this time as this is considered a normal finding.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?

Place electronic temperature probe in the midaxillary area.

The nurse is planning to instruct a new mother on care of the newborn. Which instructions support the 2020 National Health Goals for the newborn? Select all that apply.

Place the infant on the back to sleep. Continue to breast-feed the baby until age 6 months. Do not provide the baby with a bottle while falling asleep.

When the nurse performs the Ortolani maneuver, which action would be appropriate? Select all that apply.

Place the newborn in a supine position. Attempt to abduct the hips 180 degrees while applying upward pressure

A neonate is born, and the nurse realizes that the infant is at risk for evaporative heat loss. Which intervention would best prevent this from occurring?

Wrap the infant in a warm, dry blanket. Evaporation is one of the 4 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.

The experienced labor and delivery nurse knows to evaluate progress in active labor by using which simple rule? a) 1 cm/hour for cervical dilation b) 1/4 cm/hour for cervical dilation c) 1/2 cm/hour for cervical dilation d) 2 cm/hour for cervical dilation

a) 1 cm/hour for cervical dilation Rationale: In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Assess the woman's fundus. b) Begin an IV infusion of Ringer's lactate solution. c) Call the woman's health care provider. d) Assess the woman's vital signs.

a)Assess the woman's fundus. Explanation: In order to have a suggested idea of the location of the bleeding the nurse would need to assess the funds of the patient first. Although all actions may be appropriate, they would not have the priority of fundal assessment.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Which of the following should the nurse suspect is the potential diagnosis? a) Mastitis b) Engorgement c) Plugged milk duct d) Breast yeast

a)Mastitis Explanation: Mastitis usually occurs 2-3 weeks after delivery and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy. The scenario described is not indicative of a plugged milk duct or engorgement. Breast yeast is a distracter for this question.

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia. p 837

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time? a) < 8 hours b) < 3 hours c) < 4 hours d) < 5 hours

b) < 3 hours Rationale: Precipitous labor is completed in less than 3 hours.

A primigravida at 28 weeks' gestation comes to the clinic for a check-up. She tells the nurse that her mother delivered both of her children prematurely, and she is afraid that the same will happen to her. What can the nurse inform her about the risk factors associated with premature births? (Select all that apply.) a) Large-for-gestational age fetus b) History of previous preterm birth c) Current multiple gestation pregnancy d) Uterine or cervical abnormalities e) Previous Cesarean section

b) History of previous preterm birth c) Current multiple gestation pregnancy d) Uterine or cervical abnormalities Rationale: The top three risk factors for premature birth are history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities.

Which of the following actions could you initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position? a) Apply ice packs to her lower back. b) Massage her lower back. c) Place her in a Trendelenburg position. d) Urge her to maintain a prone position.

b) Massage her lower back. Rationale: Counterpressure against the woman's back by a support person can be helpful in reducing this type of pain.

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the physician informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? a) Anterior fetal position b) Transverse lie c) Occipitoposterior position d) Cephalic presentation

b) Transverse lie Rationale: A transverse lie, in which the fetus is more horizontal than vertical, occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelves.

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which of the following? a) hypertonic contractions b) precipitous labor c) hypotonic contractions d) none of the above

b) precipitous labor Rationale: When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place(precipitous labor).

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?

Prevent infection of the eyes from vaginal bacteria

The nurse is explaining to the new parents the various substances which will be administered to their newborn within a few hours of birth. Which explanation should the nurse prioritize as the best rationale for administering vitamin K?

Provides blood clotting factors

Over 75% of women who give birth experience postpartum depression. a) True b) False

b)False Explanation: Although almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal "blues") after childbirth, these feelings develop into postpartum depression in about 20%.

The majority of women who experience postpartal psychosis had no symptoms of mental illness before pregnancy. a) True b) False

b)False Explanation: The majority of women who experience postpartal psychosis had symptoms of mental illness before pregnancy.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright red bleeding stops. The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptives.

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar

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

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left or right occiputo-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior. pg 759

A physician orders oral tocolytic therapy for a woman with preterm labor. Which agent would the nurse be least likely to administer? a) Nifedipine b) Terbutaline c) Magnesium sulfate d) Indomethacin

c) Magnesium sulfate Rationale: Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Terbutaline is given intravenously during the initial period and then switched to the oral route for maintenance.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and delivery. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm. dilated. She continues to report severe pain in her back with each contraction. The patient finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain? a) Nongynecoid pelvis b) Breech presentation c) Occiput posterior position d) Fetal macrosomia

c) Occiput posterior position Rationale: A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

A patient is 23 weeks gestation and was admitted for induction and delivery after noting the infant was an intrauterine fetal death. The patient had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death? a) Genetic abnormality b) Preeclampsia c) Placental abruption d) Premature rupture of membranes

c) Placental abruption Rationale: The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes, nor the possibility of preeclamsia.

While in labor a woman with a prior history of cesarean birth complains of light-headedness and dizziness. The nurse assesses the patient and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms? a) Umbilical cord compression b) Hypertonic uterus c) Uterine rupture d) Placentea previa

c) Uterine rupture Rationale: The patient with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage and in this patient a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, nor umbilical cord compression.

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:

harlequin sign.

The AGPAR score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color

A nursing student will pick which value as a correct laboratory value for a newborn?

hemoglobin (HBG) 17 to 20 g/dL 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 completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature?

increased amounts of vernix

After teaching a class about various methods for cervical ripening, the instructor determines that the teaching was successful when the class identifies which of the following as a surgical method? a) Prostaglandin b) Laminaria c) Breast stimulation d) Amniotomy

d) Amniotomy Rationale: Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

A woman whose fetus in in the occiput-posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain? a) Performing acupuncture on the back b) Applying a heating pad to the back c) Applying ice to the back d) Applying counter pressure to the back

d) Applying counter pressure to the back Rationale: Counter pressure applied to the lower back with a fisted hand sometimes helps the woman cope with "back labor" associated with occiput-posterior positioning. The others are not recommended or used techniques for a woman in labor with back pain.

The nurse is assessing the woman who has a forceps-assisted birth for complications. Which of the following would be least likely to occur in the mother? a) Perineal hematoma b) Cervical lacerations c) Infection of episiotomy d) Caput succedaneum

d) Caput succedaneum Rationale: Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps- assisted birth. Maternal complications include tissue trauma, such as lacerations of the cervix, vagina, and perineum, hematoma, extension of episiotomy into the anus, hemorrhage, and infection.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which of the following conditions in the client is likely to increase the risk for shoulder dystocia? a) Pendulous abdomen b) Preterm delivery c) Nullipara d) Diabetes

d) Diabetes Rationale: Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position, not with shoulder dystocia.

The nurse providing care for a woman with preterm labor on terbutaline (Brethine) would include which of the following assessments for safe administration of the drug? a) Deep tendon reflexes. b) Breath sounds. c) For elevated blood glucose d) For tachycardia

d) For tachycardia Rationale: Tachycardia and palpitations are commons side effects of the drug terbutaline. Elevated blood glucose is a fetal side effect but not noted to assess with the mother. Deep tendon reflexes and breath sounds are not assessments needed for the safe administration of Brethine.

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? a) Notify the birth attendant. b) Slow the oxytocin infusion to the initial rate. c) Continue to monitor contractions and fetal heart rate. d) Stop the infusion immediately.

d) Stop the infusion immediately. Rationale: The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.

A nursing instructor identifies which of the following as increasing the chances of infection when coupled with prolonged labor? a) age of mother b) number of previous pregnancies c) multiple births d) ruptured membranes

d) ruptured membranes Rationale: The risk for infection increases during prolonged labor particularly in association with ruptured membranes. The other options do not increase the risk of infection during labor.

A client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client? a) 250 ml. b) 750 ml. c) 500 ml. d) 1000 ml.

d)1000 ml Explanation: Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.

A postpartal woman with a thrombophlebitis tells you that her leg is very painful. Which of the following actions would be most appropriate to relieve this pain? a) Urge her to walk to relieve muscle spasm. b) Apply ice to her leg above the knee. c) Massage the calf of her leg. d) Keep covers off the leg.

d)Keep covers off the leg. Explanation: Pressure or cold on the leg can interfere with blood circulation. Massaging the leg or urging her to walk could cause a clot to move and become a pulmonary embolus.

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour? a) Vital signs b) Complete blood count c) Urine volume excreted d) Pad count

d)Pad count Explanation: The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

A nurse is caring for a client with a postpartum laceration. Which of the following nursing diagnoses would be most appropriate? Select all that apply. a) Ineffective tissue perfusion b) Risk for disuse syndrome c) Risk for injury d) Impaired tissue integrity e) Ineffective thermoregulation

d)• Impaired tissue integrity c)• Risk for injury a)• Ineffective tissue perfusion Explanation: The nursing diagnoses associated with postpartum laceration include ineffective tissue perfusion, risk for injury, and impaired tissue integrity. Ineffective thermoregulation is a nursing diagnosis associated with an infection such as urinary tract infections. Risk for disuse syndrome is a nursing diagnosis associated with thromboembolic disorders.

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?

dehydration The anterior fontanelle can be felt as a soft spot. It should not appear indented (a sign of dehydration) or bulging (a sign of increased intracranial pressure) when the infant is held upright. Vernix caseosa is the white, cream cheese-like substance that serves as a skin lubricant in utero. Some of it is invariably noticeable on a term newborn's skin, at least in the skin folds, at birth. Cyanosis is a condition of decreased oxygenation that results in the skin having a blue hue. pg 851

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?

drop in estrogen and progesterone levels after birth Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

Which clinical manifestation in a woman with deep vein thombosis (DVT) should the nurse report immediately?

dyspnea Dyspnea in any client with a DVT may be an indicator the clot has moved from the original site to the lungs. This is an emergency. A client who has a DVT would be expected to have calf pain, pyrexia, and edema.

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?

intubation and suctioning of the trachea

The nurse assesses the client who is one hour postpartum and observes a heavy steady gush of bright red blood from the vagina in the presence of a firm fundus. What is the most likely cause of this finding?

lacerations A gush of blood with a firm uterus is more likely to occur from a laceration rather than from the uterine atony. This type of bleeding is usually bright red in color rather than the dark red color of lochia. A perineal hematoma presents as a bulging, swollen mass on the perineum. Uterine infection typically presents with a foul smelling discharge.

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing The newborn may be in pain if the following are exhibited: sudden high-pitched cry; facial grimace with furrowing of brown and quivering chin; increased muscle tone; oxygen desaturation; body posturing, such as squirming, kicking, and arching; limb withdrawal and thrashing movements; increase in heart rate, blood pressure, pulse, and respirations; fussiness and irritability

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence?

lack of thoracic compressions during birth A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.

At the hospital, a client is attached to the fetal monitor for uterine rupture. The nurse would assess for which pattern indicating change in the uterus impacting the fetus?

late decelerations When the fetus is being deprived of oxygen the fetus will demonstrated late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.

An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?

length of labor A prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal birth, and Rh status of the client do not place the mother at increased risk

A newborn is designated as extremely low birth weight. The nurse understands that this newborn's weight is:

less than 1,000 g. An extremely low-birth-weight newborn weighs less than 1,000 g. A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birth-weight newborn typically weighs about 2,500 g. p. 834

A newborn is designated as very low birth weight. When weighing this newborn, the nurse would expect to find which weight?

less than 1,500 g

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours Precipitous labor is completed in less than 3 hours.

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider?

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?

lethargy and hypotonia The nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?

limited voluntary muscle activity Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.

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 Lochia rubra is red; it lasts for the first few days of the postpartal period.

A nursing instructor teaching about risk factors associated with preterm labor should discuss which demographic and lifestyle issues? Select all that apply.

low socioeconomic status smoking high level of stress alcohol use Demographic and lifestyle risk factors associated with preterm labor are extremes of maternal age (younger than 17 years or older than 35 years), low socioeconoomic status, smoking, alcohol or drug use, high levels of stress, and long working hours. Infection and hypertension are medical risk factors and not demographic or lifestyle factors.

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?

macrosomia Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, cephalopelvic disproportion, uteroplacental insufficiency, meconium aspiration, and intrauterine infection. Amniotic fluid volume begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios. Hemorrhage, infection, and dystocia are risk to the mother not the fetus.

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?

magnesium sulfate Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. It is not a tocolytic agent. pg 769

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

mastitis Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid. pg 837

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

moderate Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?

on admission to the nursery Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed.

How does the nurse position the infant experiencing respiratory difficulty?

on the back with the head elevated 15 degrees

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo. p. 858

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:

place a hand gently on the fetal head to guide birth. If a head is controlled as it emerges, trauma to internal vessels or to the maternal cervix is less apt to occur.

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

placental factors

A preterm infant receives surfactant by lung lavage. What intervention should the nurse perform immediately? Select all that apply.

placing the infant in an upright position not suctioning the airway

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?

polycythemia, probably due to chronic fetal hypoxia

A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?

reflex The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.

A nurse is preparing a refresher program for a group of staff nurses returning to work in the neonatal nursery. As part of the program, the nurse will describe the process of nonshivering thermogensis as the neonate's primary mechanism for producing heat. Place the steps below in the order that the nurse would use to describe this process. All options must be used.

release of norepineprhine breakdown of triglycerides increase in cardiac output warming of blood When the newborn experiences a cold environment, norepinephrine is released. This in turn stimulates brown fat metabolism by breaking down triglycerides. Cardiac output increases, increasing blood flow through the brown fat tissue. Subsequently, this blood becomes warmed as a result of the increased metabolic activity of the brown fat.

After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition?

reports of severe back pain Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet. Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction.

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:

taking-in, taking-hold, letting-go. The new mother makes progressive changes to know her infant, review the pregnancy and labor, validate her safe passage through these phases, learn the initial tasks of mothering, and let go of her former life to incorporate this new child.

A client who has just given birth to a baby girl demonstrates behavior not indicative of bonding when she performs which action?

talks to company and ignores the baby lying next to her Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. The mother initiates bonding when she caresses her infant and exhibits certain behaviors typical of a mother tending to her child. Ignoring the infant while talking to visitors is not an example of proper bonding.

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea-colored urine

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally. The nurse should administer 0.5 to 1 ml/kg/hr of breast milk enterally to induce surges in gut hormones that enhance maturation of the intestine. Administering vitamin D supplements, iron supplements, or intravenous dextrose will not significantly help the preterm newborn's gut overcome feeding difficulties.

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously.

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously. The infant is demonstrating signs and symptoms of significant hypoglycemia. IV dextrose should be administered to the term newborn intravenously when the blood glucose level is less than 40 mg per dL, and the newborn is symptomatic for hypoglycemia. Administration of IV glucose assists in stabilizing blood glucose levels. Providing oral glucose feedings or placing the infant on a radiant warmer will not help maintain the glucose level. Monitoring the infant's hematocrit level is not a priority and not related to the problem at hand. pg 840

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

A nurse is caring for a client at 38 weeks gestation who is diagnosed with chorioamnionitis. On which intervention should the nurse place priority?

Administer oxytocin. Chorioamnionitis is an indication for labor induction. The WBC, temperature, and amniotic fluid are not priority to assess because the nurse already knows the client has chorioamnionitis.

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn?

Administer the medication into the anterolateral muscle.

The parents of a newborn are concerned that the different procedures are causing pain for their newborn. Which action should the nurse prioritize to address the parent's concerns?

Advocate and use effective treatment methods that cause no pain or less pain.

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed?

After the newborn has completed the antibiotic therapy

At an amniocentesis just prior to birth, a fetus's lecithin/sphingomyelin ratio was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth?

Alveolar collapse on expiration

The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered?

Alveolar collapse on expiration

The nurse is caring for a client within the first four hours of her cesarean birth. Which nursing intervention would be appropriate to prevent thrombophlebitis?

Ambulate the client as soon as her vital signs are stable. The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure

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. Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. Witch hazel compresses are used for hemorrhoidal discomfort. Glycerin-based ointments can be used to address nipple pain.

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.

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first?

Ask the client to elaborate on her feelings. The client's affect is consistent with postpartum blues, a transient source of sadness experienced during the first week after birth. The nurse should offer support to the client and encourage her to discuss her concerns and feelings. The client's emotional state is normal and contacting the care provider is not indicated. Discussing the client's feelings with family members is a violation of confidentiality and is not an appropriate action. Documenting the interaction is indicated but should take place after the encounter is completed.

The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning? Asking for assistance changing a diaper Making eye contact with the baby Calling the baby "it" or "they" Breastfeeding the infant on demand

Calling the baby "it" or "they" Many new parents will need assistance with diaper changes; this is not a flag for concern. Making eye contact and breastfeeding are positive interaction behaviors. If the mother calls the baby "it" and does not use the child's name, this is a sign that further information needs to be gathered and assessments should be completed.

The nurse notes that a client's uterus, which was firm after the fundal massage, has become "boggy." Which intervention would the nurse do next?

Check for bladder distention, while encouraging the client to void. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

Check the lochia. The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (30.0° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus.

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature.

A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation?

Continue bag and mask ventilation only.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?

Continue to monitor the woman's temperature every 4 hours; this finding is normal. A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

Cover the glans generously with petroleum jelly.

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g, and the primary care provider prescribes 0.1 mL/kg. How much would the nurse administer?

0.15 mL The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL. p 848

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.

0.3

The nurse is preparing to administer an intramuscular injection to a newborn. The nurse will ensure the maximum amount per injection is what?

0.5

A postpartum mother is recovering from a cesarean delivery and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: Morphine Sulfate 8 mg IV q 4 hours prn for pain greater than 6. Morphine Sulfate comes in 10 mg/mL. How many milliliters of morphine would the nurse administer to this client using slow push over 5 minutes? Record your answer using one decimal place.

0.8 mL The on-hand medication is morphine sulfate 10 mg/mL. The ordered dose is 8 mg, so the nurse would calculate the dose as follows: 10 mg/1 mL = 8 mg/X mL Cross multiply, 10X = 8 mL Divide 8 by 10 to get 0.8 mL

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad. If the morning assessment is done relatively early, it is possible that the client has not yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, would not be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse would not want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching?

Avoid over-the-counter (OTC) salicylates. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact with the mother. The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family?

Help the mother provide kangaroo care.

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 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 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 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean 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 nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

Hep B

Which assessment on the third postpartal day would make the nurse evaluate a woman as having uterine subinvolution?

Her uterus is at the level of the umbilicus. A uterus involutes at a rate of one finger width daily. On the third postpartal day, it is normally three finger widths below the umbilicus.

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?

Hyperbilirubinemia Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to an increased hemolysis. Complications of this process include hyperbilirubinemia.

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 30 minutes

Which assessment finding indicates to the nurse that a newborn has hip subluxation?

Inability of the right hip to abduct

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply.

Increase the infant's hydration. Offer early feedings. Initiate phototherapy. Hydration, early feedings, and phototherapy are measures that the nurse should take to reduce bilirubin levels in the newborn. Stopping breastfeeding or administering vitamin supplements will not help reduce bilirubin levels in the infant.

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

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. Begin kangaroo care for the newborn.

The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority?

Initiate early oral feedings. Metabolic needs are increased for catch-up growth in the SGA newborn. Initiate early and frequent oral feedings. Neonatal hypoglycemia is a major cause of brain injury since the brain needs glucose continuously as a primary source of energy. A newborn stressed at birth uses up available glucose stores quickly with resulting hypoglycemia. A plasma glucose concentration at or below 40 mg/dL necessitates and frequent oral feedings. With the loss of the placenta at birth, the newborn now must assume control of glucose homeostasis through oral feedings. The others at this time are not a priority. pg 851

A full-term pregnant client is being assessed for induction of labor. Her Bishop score is less than 6. Which prescription would the nurse anticipate?

Insert a Foley catheter into the endocervical canal. A Bishop score of less than 6 indicates that a cervical ripening method should be used before inducing labor. A low Bishop score is not an indication for cesarean birth; there are several other factors that need to be considered for a cesarean birth. A Bishop score of less than 6 indicates that vaginal birth will be unsuccessful and prolonged because the duration of labor is inversely correlated with the Bishop score.

A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate?

Basic immunizations are given according to the chronologic age of an infant.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?

Bathe the baby under a radiant warmer. Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.

When educating the postterm pregnant client, what should the nurse be sure to include to prevent fetal complications?

Be sure to monitor fetal movements daily. The nurse should be sure to teach the postterm client to monitor fetal movements daily.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?

Instill 0.5% ophthalmic erythromycin.

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 Postpartum women should consider low-impact activities such as walking, biking, swimming, or low-impact aerobics as they resume physical activity. They should also consider a regular program of Kegel exercises; losing weight, if necessary; avoid smoking; limiting intake of alcohol and caffeinated beverages; and adjusting the fluid intake to produce a 24-hourly output of 1,000 mL to 2,000 mL.

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle.

The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?

Begin supervised feedings for the newborn. Hypoglycemia in a neonate is defined as blood glucose value below 40 mg/dL. Supervised breastfeeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcome, and hence aggressive screening and treatment is recommended. Monitor blood glucose levels within 30 minutes of birth, and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia.

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

Bilirubin level went from 15 to 11 The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice. A serum bilirubin is the best way to determine whether the jaundice is improving. The other listed methods will not address the needed information. pg 575

A nurse teaches new parents that the bestway to help prevent infections in the newborn is which method?

Breastfeed. A major source of IgA, which helps in immunity, is human breast milk. Thus, breastfeeding is believed to have significant immunological advantages over formula. The other options such as keeping them in for a month and keeping them warm will not help prevent infections. Keeping the child away from people who have an infection might stop them from getting that infection. Doing so will not help build up the infant's immunity.

A client is admitted to the unit in preterm labor. In preparing the client for this therapy, the nurse anticipates that the client's pregnancy may be prolonged for how long when this therapy is used?

2 to 7 days Tocolytic drugs may prolong the pregnancy for 2 to 7 days. During this time, steroids can be given to improve fetal lung maturity, and the woman can be transported to a tertiary care center.

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?

2 weeks Once postpartum blues are determined to be the likely cause of her mood symptoms, the nurse can offer anticipatory guidance that these mood swings are commonly experienced and usually resolve spontaneously within a week and offer reassurance. Women should also be counseled to seek further evaluation if these moods do not resolve within two weeks, as postpartum depression may be developing.

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval?

2 weeks The general rule of thumb is for a woman who had a cesarean birth be seen within 2 weeks after hospital discharge, unless the primary care provider has indicated otherwise or if the client develops signs of infection or has other difficulties.

For several hours after birth a multigravida client who experienced a much more difficult labor this time than any time previously, wants to talk about why the birthing process was so hard for her. She is focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should the nurse handle this situation?

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. 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 reports she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement?

Encourage the client to eat more fiber rich foods. Encouraging fiber rich foods will help with prevention of constipation. The client needs plenty of water, to ambulate, and take stool softeners if ordered by the provider. Offering a stimulant laxative is not appropriate. Adding dairy products to the diet may be a good thing, but will not generally produce a bowel movement. Holding the feces until there is a strong urge to defecate will only increase the risk of constipation as well as possible resultant complications.

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?

20th Appropriate for gestation age infants fall between the 10th and 90th percentile for weight.

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh:

4,000 g or more. Macrosomia occurs when the fetus measures 4,000 g (8.13 lbs) or more at birth and complicates approximately 10% of all pregnancies. The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

Which finding would the nurse describe as "light" or "small" lochia?

4-inch stain or a 1 to 25 ml loss 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

A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?

40 to 60 breaths per minute When performing newborn resuscitation, the nurse would ventilate at a rate of 40 to 60 breaths per minute.

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

A newborn is 7 minutes old. Her heart rate is 92 bpm, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score?

5

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 Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth. pg 576

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5. A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

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. 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.

When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voiding per day as a good indicator of adequate fluids?

6 to 8 From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake.

During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status?

6 to 8 weeks after pregnancy During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their prepregnant state. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal.

The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women? 40% 85% 25% 100%

85% Postpartum blues, or mild depression during the first 10 days after giving birth, affects up to 85% of women who give birth. More intense depression during this period is referred to as postpartum depression, which affects approximately 10% to 15% of postpartum clients. Postpartum depression can be severe with negative implications for maternal and neonatal well-being.

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m. If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.

The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration? Excessive oxytocin Mastitis Engorgement Blocked milk duct

Engorgement The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. Mastitis or blocked milk ducts do not typically develop until there is fully established breastfeeding. Oxytocin would not be responsible for this.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently. The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?

Expose the newborn's bottom to air several times a day.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?

Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendations would the nurse not make to this mother?

Feeding the infant more formula whenever she begins to fuss

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?

Focus on decreasing blood viscosity by increasing fluid volume.

A nurse is caring for a 38-year-old overweight client 24-hours post cesarean birth. The client is reporting calf tenderness. Which should the nurse do first?

Have the client rest with the extremity elevated. The client is probably experiencing a deep vein thrombosis (DVT). The nurse would maintain bed rest with the effected extremity elevated until the diagnosis could be confirmed. Once the diagnosis is confirmed, and anticoagulant may be prescribed. It is not priority to determine the severity of the pain or a respiratory rate.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? Notify the primary care provider, and document the findings. Have the client void, and then massage the fundus until it is firm. Assess a full set of vital signs. Check and inspect the lochia, and document all findings.

Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

A baby is born with congenital rubella. Which of the following would be an important assessment to be made before hospital discharge?

Hearing assessment

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?

A full bladder or rectum can impede fetal descent. Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent. pg 759

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

A client who recently gave birth to her third child expresses a desire to have her older two come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request? "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break." "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover."

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns?

"Breastfed babies need supplements of glucose water to help lower bilirubin levels."

The mother of a preterm infant tells her nurse that she would like to visit her newborn who is in the neonatal intensive care unit (NICU). Which response by the nurse would be the most appropriate?

"Certainly. You will need to wash your hands and gown before you can hold him, however." The nurse should be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them. p 852

A client who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. What would be the best response by the nurse?

"Different fetal positions can cause prolonged labor and back pain." Fetal malposition can cause prolonged labor. A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The other answers do not address the client's question. pg 759

The nursing student demonstrates an understanding of dystocia with which statement?

"Dystocia is diagnosed after labor has progressed for a time." Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement?

"His stomach can hold approximately 10 ounces." A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter which leads into the stomach and nervous control of the stomach are immature.

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "My episiotomy should begin to heal and feel better over the next few weeks" "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know." "I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "I need to let the doctor know if my lochia begins to have a foul smell."

"I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the doctor needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul smelling both indicate a possible infection and the doctor needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks.

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others."

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others." Birth weight variations include appropriate for gestational age (AGA), which describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. This describes approximately 80% of all newborns. Infants who are appropriate for gestational age have lower morbidity and mortality than other groups. pg 834

The client is anxious about her prolonged pregnancy. She informs the nurse she has been doing research on the Internet and has read about certain herbs that can help to induce labor. Which response from the nurse would be appropriate?

"Please talk to your primary care provider first to ensure it is safe." It is important that the primary care provider knows if and when the client is using herbal supplements to ensure there will be no danger to the woman or fetus. The risks and benefits of these agents are unknown. None have been evaluated scientifically, and thus none can be recommended regarding their efficacy or safety. The statement about personal use is inappropriate because the nurse should not reveal personal information. Telling the client that the herbs will complicate the situation is inappropriate because the statement is judgmental and there is no information, whether positive or negative that the herbs can be harmful. The statement about doing something stupid is demeaning to the client. pg 778

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be: "Often, when a postpartum woman perspires like you are reporting, it means that they have an infection." "Many women sweat after delivery but you seem to be perspiring far more than normal. I'll call the doctor." "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." "I need to get your vital signs and check your fundus to be sure you are not going into shock."

"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." Diaphoresis often occurs in postpartum women as a way to get rid of both excess water and waste through the skin. It is not uncommon for a woman to wake up drenched in sweat during the first few days following delivery. This is a normal finding and is not a cause for concern.

Which instruction should the nurse provide to a breastfeeding woman experiencing breast engorgement?

"Take a warm shower just before feeding your infant." Standing in a warm shower or applying warm compresses immediately before feedings will help soften the breasts and nipples to allow the newborn to latch on more easily and will enhance the let-down reflex. Wearing a tight supportive bra all day is appropriate for the woman who is not breastfeeding. Frequent emptying of the breasts helps to resolve engorgement, so the mother should be encouraged to feed the newborn, which would involve touching her breasts and nipples. The breastfeeding woman should apply cold compresses but not ice to her breasts between feedings to reduce swelling.

A client is 32 weeks pregnant and sent home on modified bedrest for preterm labor. She is on tocolytics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse?

"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor." The client needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider says it is safe.

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

A mother is concerned because her newborn daughter has lost 8 ounces within 3 days after birth. What response by the nurse correctly addresses this concern?

"This is a normal and expected finding." The infant has a 5% to 10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake. The nurse would not tell the new mother that her infant needs to be checked for an illness; this is inappropriate because if the infant were ill, there would be other symptoms besides weight loss. Weight loss in a newborn is a normal finding. A new breastfeeding mother should not supplement feedings with formula.

During labor, a woman at 41 weeks' gestation notes her amniotic fluid is leaking and is green in color. She is asking the nurse why the fluid is green. What is an appropriate response by the nurse?

"This is meconium-stained fluid from the baby." Green tinted amniotic fluid is most often a sign of the infant having a bowel movement in the uterus, called mecnomium-stained fluid. This is more typical in a postdates pregnancy. Green-stained amniotic fluid is not a normal color for amniotic fluid. However, it does not mean the mother has an infection and needs antibiotics, nor does it does mean there might be a yeast infection present or indicate the need for a culture of the fluid.

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." "Try shushing her loudly." "Encourage her to suck." 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). pg 581

The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem?

"We will need to plan for special care to help with learning disabilities."

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student makes which statement?

"When the baby is ready to leave the uterus, it takes its first breath." Changes in circulation begin immediately at birth as the fetus separates from the placenta. When the umbilical cord is clamped, the first breath is taken and the lungs begin to function.

A newborn has scheduled heel sticks for bilirubin checks every 4 hours. The mother asks the nurse "what can be done to calm my baby after those heel pricks?" What is the nurse's most appropriate response?

"You can give your baby a sucrose solution by bottle for pain relief."

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?

McRoberts maneuver McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next?

Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The healthcare provider would be notified if no other interventions help the client.

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next? Notify the healthcare provider. Perform urinary catheterization. Administer oxytocin IV. Insert a 20 gauge IV.

Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The healthcare provider would be notified if no other interventions help the client.

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority?

Prepare for repeat hematocit levels q12h.

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority?

Prepare for repeat hematocit levels q12h. Newborn infants of diabetic mothers (IDM) are at risk for polycythemia. A priority for the nurse is to observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy) and monitor blood results with hematocrit levels repeated every 12 hours. Blood glucose levels would be monitored more often than Q6H. Bleeding disorders do not correlate with the situation. CPAP may be needed but not as the priority. pg 836

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth. Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth. pg 775

The nurse is admitting a client in labor. The care provider determines that the fetus is in a transverse lie and not responsive to Leopold's maneuvers. What intervention should the nurse provide for the client?

Prepare the client for a cesarean birth. If a transverse lie persists, the fetus cannot be born vaginally. The most common method the practitioner uses to diagnose fetal malpresentation is Leopold's maneuvers followed by ultrasound. Sometimes the practitioner notes transverse lie by looking at the contour of the abdomen, which tends to be in the shape of a football, wider side to side than top to bottom. pg 759

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth. The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth. pg 783

A multipara presents to the hospital after 2 hours of labor. The fetus is presenting in transverse lie. The nurse notifies the primary care provider and takes which action?

Prepare to assist with external version or prep for a cesarean birth. Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position or be born via a cesarean birth. Piper forceps are used in the birth of a fetus that is in the breech position. Nitrazine and fern tests are done to assess if amniotic fluid is leaking from the sac into the vagina. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" that is characteristic of occiput posterior positioning. pg 758

At birth there are multiple changes in the cardiac and respiratory systems. What is one of the changes to occur at birth in the cardiovascular system?

Pressure changes occur and result in closure of the ductus arteriosus. The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs is not a function of the cardiovascular system; it is a function of the respiratory system. Again, the removal of fluid from the alveoli is not a function of the cardiovascular system. The oxygen content of the blood increases; it does not decrease.

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. The nurse should promote early breastfeeding to provide fuels for nonshivering thermogenesis. The nurse can bathe the newborn if he or she is medically stable. The nurse can also use a radiant heat source while bathing the newborn to maintain the temperature. Skin-to-skin contact with the mother should be encouraged, not discouraged, if the newborn is stable. The infant transporter should be kept fully charged and heated at all times.

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. The nurse is alone with her and notices that the umbilical cord is hanging out of the vagina. What should the nurse do next?

Put her in bed immediately, call for help, and hold the presenting part of the cord. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, when the presenting part compresses the cord oxygen, and nutrients are cut off to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and the nurse does not leave the woman. A vaginal birth is contraindicated in this situation.

A couple has just experienced intrauterine fetal demise. Which action by the nurse would be least effective in assisting them?

Refrain from discussing the situation with the couple. The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time. pg 784

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?

Retinopathy of prematurity Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client?

Risk for fatigue related to chronic bleeding due to subinvolution Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

Which nursing diagnosis has the highest priority for a postpartum client?

Risk for injury: postpartum hemorrhage related to uterine atony The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?

RoP

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?

Schedule home visits for high-risk families. To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.

Which maternal reaction is the most concerning?

She neglects to engage with or provide care for the baby and shows little interest in it. A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with "postpartum blues".

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?

She should continue to breastfeed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?

Showing increased confidence when caring for the newborn Independence with self-care is an important aspect of the taking-hold phase. 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. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? Showing increased confidence when caring for the newborn Pointing out specific features in the newborn Having feelings of grief or guilt Talking about her labor experience to others around her

Showing increased confidence when caring for the newborn Independence with self-care is an important aspect of the taking-hold phase. 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. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area. Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death.

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?

Stools should be yellow-gold, loose, and stringy to pasty. The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor. pg 577

A woman has just given birth vaginally to a newborn. Which action would the nurse do first?

Suction the mouth and nose.

A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next?

Suction the mouth then the nose.

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? Recommend rooming-in to foster attachment and confidence by the mother. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge. Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.

Which client would the nurse be most concerned about on postpartum day 1?

Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85 Postpartum women may have an elevated temp to 100.4° F (38° C) for 24 hours after birth; they may also have decreased pulse a few weeks after birth. The elevated BP is a concern, as a postpartum woman is still at risk of developing preeclampsia even after birth. This makes the other options incorrect.

A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What signs of distress would validate the nurse's concerns?

Temperature instability

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.

While educating a class of postpartum clients before discharge home after birth, one woman asks when "will I stop bleeding?" How should the nurse respond?

The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks. The lochia changes color in the first few weeks postpartum; the active bleeding stops in the first week, but a white discharge may continue for up to 6 weeks after birth. Bleeding does not occur "off and on"; the bleeding stops during the first week but a discharge continues to occur. The discharge may continue for up to six weeks, not just bleeding.

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding?

The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding?

The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. A hematocrit above 65% is considered elevated and polycythemia is diagnosed. However, to get an accurate venous reading, a central venous hematocrit needs to be drawn to verify the value. Drawing the blood in 8 hours does not address the problem at present, and the infant does not need a partial exchange transfusion immediately. Health care providers will decide if this is needed after monitoring the infant for symptoms and following the central hematocrit levels. p.837

A male baby is born at 5:15 a.m. on a Wednesday. At 1:15 p.m. on the same day, the nurse notes yellow staining of the skin on the head and face of this infant. What does this finding likely indicate?

The infant has pathologic jaundice. Bilirubin is released as blood cells are broken down in the body of the infant. The liver is immature and not able to break down the bilirubin, and the infant demonstrates excessive bilirubin the blood by a yellow tinged skin. Elevated bilirubin levels in the first 24 hours of life are considered pathologic. Physiologic jaundice is characterized by jaundice that occurs after the first 24 hours of life (usually on day 2 or 3 after birth). Jaundice appears first on the head and face; then as bilirubin levels rise, jaundice progresses to the trunk and then to the extremities in a cephalocaudal manner. Hyperbilirubinemia, high levels of unconjugated bilirubin in the bloodstream (serum levels of 4 to 6 mg/dL and greater), can lead to jaundice. pg 575

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?

The infant is attempting self-consoling maneuvers. The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation. pg 581

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?

The infant was a preterm, low birth weight and small for gestational age

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?

The neonate is small for its gestational age.

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?

The neonate is small for its gestational age. Small for gestational age (SGA) describes newborns that typically weigh less than 2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. In some SGA newborns, the rate of growth does not meet the expected growth pattern. These infants are considered to have fetal growth restriction resulting in pathology. pg 834

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth.

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? Try to avoid carrying the baby for a few days. Maintain correct posture and positioning. Apply ice to the sore joints. Soak in a warm bath several times a day.

Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding? At the pubic bone One fingerbreadth below the umbilicus Two fingerbreadths below the umbilicus Level with the umbilicus

Two fingerbreadths below the umbilicus Immediately after delivery, the uterine fundus should be at the level of the umbilicus. One day postpartum, the height is one fingerbreadth below the umbilicus and by Day 2, the fundal height is two fingerbreadths below the umbilicus.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position. pg 767

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.

Use sterile gloves for an invasive procedure. Initiate universal precautions when caring for the infant. Avoid coming to work when ill. To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it. pg 852

A woman states that she still feels exhausted on her second postpartal day. The nurse's best advice for her would be to do which action?

Walk with the nurse the length of her room. Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Massage the breasts when they are painful. Express small amounts of milk when they are too full. Run warm water over the breast in the shower. Wear a tight, supportive bra.

Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.

A nurse is caring for a nonbreastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?

Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

A nurse is caring for a nonbreast-feeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing. Apply warm compresses.

Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?

Wear clean gloves.

Which instruction would the nurse include in the teaching plan for a postpartal client with a history of thromboembolism to reduce the risk of a recurrence?

Wear support hose or antiembolic stockings. When caring for a postpartal client with a history of a thromboembolic disorder, the nurse should instruct the client to wear support hose or antiembolic stockings. The nurse should instruct the client specifically to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly. The nurse should instruct the client to refrain from flexing the muscles at the groin, and the nurse should instruct the client to avoid pressure at the back of the knees, not on the thigh muscles.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance. p 858

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? a) She should continue to breast-feed; mastitis won't infect the neonate b) She should supplement feeding with formula until the infection resolves c) She should stop breast-feeding until completing the antibiotic d) She shouldn't use analgesics because they aren't compatible with breastfeeding

a)She should continue to breast-feed; mastitis won't infect the neonate Explanation: The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding doesn't need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a) Uterine atony b) Uterine contraction c) Uterine prolapse d) Uterine subinvolution

a)Uterine atony Explanation: Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally the nurse assists the woman with perineal care and applying a new perineal pad.

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? a) Uterine bleeding present b) Foul smelling lochia c) Pain in the lower abdomen d) Uterine protrusion into the vagina

a)Uterine protrusion into the vagina Explanation: To determine if the uterine prolapse in the client is mild or severe, the nurse should assess for uterine protrusion of the cervix and uterus into the vagina. As more of the uterus descends, the vagina becomes inverted. Uterine bleeding, foul-smelling lochia, and pain or tenderness in the lower abdomen are all characteristic manifestations of late postpartum hemorrhage.

What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight?

ability to tolerate early oral feeding

What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight?

ability to tolerate early oral feeding Unlike preterm babies with low birth weights, a small for gestational age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature, and an angular and pinched face are features common to both an SGA and a preterm baby.

A nurse is reviewing the maternal history and medical record of an SGA newborn. Which finding would the nurse identify as a placental factor contributing to the newborn's current state?

abnormal cord insertion

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which primary conditions? Select all that apply.

abruptio placenta severe preeclampsia septicemia DIC is always a secondary diagnosis that occurs as a complication of abruptio placenta, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, severe preeclampsia, HELLP syndrome, septicemia, and hemorrhage.

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?

activated partial thromboplastin time The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply.

active bowel sounds passing gas nondistended abdome Finding active bowel sounds, verification of passing gas, and a nondistended abdomen are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased. Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: slightly increased. acutely decreased. acutely increased. slightly decreased.

acutely decreased. Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho D are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?

an ice pack applied to the perineum Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia?

an infant who had difficulty establishing respirations at birth Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

apnea A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress. pg 850

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? administering bromocriptine applying ice restricting fluids applying warm compresses

applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

A client has just given birth to her second child and will breastfeed. Although she wants "lots of kids," she does not want to become pregnant again until her second child is at least 2 years old. The nurse would counsel her to start using birth control at what point?

as soon as she resumes sexual activity She can ovulate even though she is not having a normal menstrual cycle. She needs to take precautions. Beginning to use birth control within 6 weeks, or within 18 months, or as soon as she stops breastfeeding is not affording her protection from getting pregnant. She should use mechanical means of birth control as soon as she resumes sexual activity.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

asymmetrical chest movement Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.

A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is:

at least 24 hours after birth.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior?

attachment Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth. This is not an example of being spoiled.

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior? engorgement involution attachment engrossment

attachment When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smoothes the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.

A pregnant woman delivers a term fetus who has died in utero. She requests time after the birth to hold her baby. What is the best response by the nurse? a) "This was nature's way of taking care of a defective baby." b) "Hold your baby as long as you like. Please let me know what I can do to help you." c) "You can hold your baby for a few minutes, but then I must take it to the nursery to do the paperwork." d) "You don't want to see your baby like this. I will take the baby away for you."

b) "Hold your baby as long as you like. Please let me know what I can do to help you." Rationale: A woman who has just received a diagnosis of fetal demise is experiencing a terrific loss. The nurse should be available to her without intruding and answer her questions honestly. He or she should encourage the woman to hold and name her baby, if she is able.

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? a) A full rectum can cause diarrhea. b) A full bladder or rectum can impede fetal descent. c) If the woman has a full bladder, labor may be uncomfortable for her. d) If the woman's bladder is distended, it may rupture.

b) A full bladder or rectum can impede fetal descent. Rationale: Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent.

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication? a) Her perineum is obviously edematous on inspection. b) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. c) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. d) She tells you she is extremely thirsty.

b) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Explanation: Postpartal women who void in small amounts may be experiencing bladder overflow from retention

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in a persistent occiput posterior position? a) Lack of cervical dilation past 2 cm b) Complaints of severe back pain c) Fetal buttocks as the presenting part d) Contractions most forceful in the middle of uterus rather than the fundus

b) Complaints of severe back pain Rationale: Complaints of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet. Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction.

Which measurement best describes delayed postpartum hemorrhage? a) Blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after delivery b) Blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after delivery c) Blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after delivery d) Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery

d)Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery Explanation: Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

A 27-year-old G1, P1 woman arrives in the emergency department accompanied by her husband and new infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when? a)Within 2 months of giving birth b)Within 5 months of giving birth c)Within 4 months of giving birth d)Within 3 months of giving birth

d)Within 3 months of giving birth Explanation: Postpartum psychosis general surfaces within 3 months of giving birth.

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change? increased progesterone levels use of anesthesia during birth decreased bladder pressure decreased intra-abdominal pressure

decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.

The nurse providing care for a woman with preterm labor on magnesium sulfate would include which assessment for safe administration of the drug?

deep tendon reflexes (DTR)s Assessing deep tendon reflexes hourly in a client receiving magnesium sulfate is appropriate as depressed DTRs are a sign of magnesium toxicity. Elevated blood glucose is a fetal side effect but not noted to assess with the mother. Assessing for depressed respiration and hypotension not tachypnea or tachycardia would be appropriate assessments needed for the safe administration of magnesium sulfate.

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication?

deep venous thrombosis Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity.

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?

dehydration

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. When reviewing maternal history, the nurse would interpret which factors as placing a newborn at risk for being LGA? Select all that apply.

diabetes mellitus multiparity history of postdates gestation Maternal factors that increase the chance of bearing an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. pg 840

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.

diabetes mellitus postdates gestation prepregnancy obesity Diabetes mellitus, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn's being large for gestational age.

A woman's nurse-midwife tells her that the woman has developed dystocia. The nurse explains that this term means:

difficult or abnormal labor. Dystocia is a general term used to describe difficult or abnormal labor. Dystocia does not indicate high blood pressure related to difficult labor, a potential for placental detachment, nor muscle weakness related to prolonged labor.

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?

difficult to separate clots If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

After an hour of administering oxytocin intravenously, the nurse assesses a woman's contractions to be 80 seconds in length. The nurse's first action would be to:

discontinue the oxytocin infusion. If uterine contractions lengthen beyond 70 seconds, there is apt to be an interference with fetal circulation. Discontinuing the infusion allows contractions to shorten in length and allows fetal nourishment

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely? nausea blood loss diuresis lactation

diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.

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 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.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open. Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function. p 842

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? progesterone hCG prolactin estrogen

estrogen 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.

The nurse assesses that the fetus of a woman is in an occiput posterior position. Which description identifies the way the nurse would expect the client's labor to differ from others?

experience of additional back pain Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.

A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:

expiratory grunting. Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen). p 845

A pregnant woman comes to the birthing center, stating she is in labor and doesn't know far along her pregnancy is because she has not had prenatal care. A physician performs an ultrasound that indicates oligohydramnios. When the patient's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this patient? a) Complications of preterm labor b) Complications of a post-term pregnancy c) Complications of placenta previa d) Placental abruption

b) Complications of a post-term pregnancy Rationale: A post-term pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) Her uterus is three finger widths under the umbilicus. b) Her uterus is at the level of the umbilicus. c) Her uterus is 2 cm above the symphysis pubis. d) She experiences "pulling" pain while breastfeeding.

b)Her uterus is at the level of the umbilicus. Explanation: A uterus involutes at a rate of one finger width daily. On the third postpartal day, it is normally three finger widths below the umbilicus.

A nurse in a normal newborn nursery receives a report on four infants. Baby A is reported as being 16 hours old, vital signs within normal limits (WNL), bilirubin 3.5 mg/dL rooming in with mother; baby B is 8 hours old, vital signs WNL, bilirubin 3 mg/dL, returning to nursery for night; baby C is 19 hours old, vital signs WNL, bilirubin 4 mg/dL, rooming in with mother; baby D is 4 hours old, vital signs WNL, bilirubin 2 mg/dL, returning to nursery for night. Which baby would the nurse assess first?

baby C Hyperbilirubinemia, high levels of unconjugated bilirubin in the bloodstream (serum levels of four to six mg/dL and greater), can lead to jaundice, a yellow staining of the skin.

Which is not a cause of jaundice in the newborn?

bilirubin hyperexcretion Overexcretion of bilirubin would not cause jaundice. Bilirubin overproduction, decreased bilirbuin conjugation, and impaired bilirubin excretion would cause hyperbilirubinemia, which leads to jaundice.

A nurse working with a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10 hours ago. The report indicates an absence of the protein, which the nurse knows indicates:

birth is unlikely within the 2 next weeks. Fetal fibronectin is a protein that helps the placenta and fetal membranes adhere to the uterus during pregnancy. A negative result (absence of fetal fibronectin) is a reliable indicator that birth is unlikely within 2 weeks following the test. It does not diagnose infection.

On assessment of a 2-day postpartum client the nurse finds that the fundus is boggy, at the umbilicus, and slightly to the right. What is the most likely cause of this assessment finding?

bladder distention The most often cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? bleeding postpartal gestational hypertension infection diabetes

bleeding Blood pressure should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.

Which measurement best describes delayed postpartum hemorrhage?

blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after birth Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

A nurse is conducting an refresher program for a group of nurses returning to work in the newborn clinic. The nurse nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional teaching is needed when the group identifies which parameter as being included in the assessment?

blood pressure

A woman has just given birth to a baby. Her prelabor vital signs were temperature: 98.8° F (37.1° C); blood pressure: 120/70 mm Hg; pulse; 80 beats/min. and respirations: 20 breaths/min. Which combination of findings during the early postpartum period are the most concerning?

blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normals from birth and need to be reported immediately. Shaking chills with a temperature of 100.3º F (37.9º C) can occur due to stress on the body and is considered a normal finding. A fever of 100.4º F (38º C) should be reported. The other options are considered to be within normal limits after giving birth to a baby.

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply.

breastfeeding early ambulation Factors that inhibit involution that would result in subinvolution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by:

bringing the newborn into the room. Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure?

brown fat The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. The brown color is derived from the fat's rich supply of blood vessels and nerve endings.

What is the primary mechanism for temperature regulation in a newborn infant?

brown fat store usage Brown fat stores are the stores 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 assist 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 nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage?

by frequently assessing uterine involution The nurse should closely assess the woman for hemorrhage after giving birth by frequently assessing uterine involution. Assessing skin turgor and blood pressure and monitoring hCG titers will not help to determine hemorrhage.

A patient who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. The best response by the nurse would be which of the following? a) "Let me help you out of bed to try walking it off." b) "Perhaps you have been in one position for too long." c) "Different fetal positions can cause prolonged labor and back pain." d) "This is just a normal part of labor."

c) "Different fetal positions can cause prolonged labor and back pain." Rationale: Fetal malposition can cause prolonged labor. A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The other answers do not address the patient's question.

When a woman in labor has reached 8 cm dilation, you notice the fetal heat rate suddenly slows. On perineal inspection, you observe the fetal cord has prolapsed. Your first action would be to a) replace the cord with gentle pressure. b) cover the exposed cord with a dry, sterile wrap. c) place her in a knee-chest position. d) turn her to her left side.

c) place her in a knee-chest position. Rationale: Keeping the pressure of the fetus off the cord improves fetal circulation. Placing the woman in a knee-chest position accomplishes this. Replacing the cord could knot it; allowing it to dry would constrict cord blood vessels.

The nursing student doing a rotation in obstetrics is talking to her preceptor about dystocia. She asks what is meant by the term "expulsive forces," better known as the "powers." The preceptor correctly tells her that the "powers" include which of the following? (Check all that apply.) a) mother's age b) analgesia c) position d) fetal development e) presentation

c) position d) fetal development e) presentation Rationale: Dystocia can result from problems or abnormalities involving the expulsive forces (known as the "powers"): presentation, position, and fetal development. The others are not included in the "powers."

The nurse recognizes that the postpartum period is a time of rapid changes for each client. Which of the following is believed to be the cause of postpartum affective disorders? a)Medications used during labor and delivery b)Lack of social support from family or friends c)Drop in estrogen and progesterone levels after birth d)Preexisting conditions in the client

c)Drop in estrogen and progesterone levels after birth Explanation: Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: T 101.2°F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs? a) Shock b) Normal vital signs c) Infection d) Dehydration

c)Infection Explanation: Temperatures elevated above 100.4°F 24 hours after delivery are indicative of possible infection.

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them? a) Disruption in fetal clotting mechanisms b) Laceration of the placenta c) Laceration of the cervix d) Disruption of placental clotting mechanisms

c)Laceration of the cervix Explanation: There are four major causes of postpartum hemorrhage: uterine atony, inability of the uterus to contract effectively; lacerations to the uterus, cervix, vagina, or perineum; retained placenta; and disruption in maternal clotting mechanisms. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors.

When working in a free clinic for children, the nurse observes a mother with her 2 week infant. Which of the following behaviors should the nurse bring to the attention of the health care provider? a) Talking to the infant and rocking the infant b) Breastfeeding the infant in public c) Non-responsive to the infant crying d) Discussing her birth with another new mom

c)Non-responsive to the infant crying Explanation: When a mother is not engaged with the infant and is demonstrating signs of not providing care or responding to the infant, there is a concern about malattachment. This needs to be reported to the health care provider for follow-up. Options A, C, and D are normal activities for a new mother who is two weeks post partum.

Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect? a) Early postpartum hemorrhage b) Late postpartum hemorrhage c) Pelvic hematoma d) Uterine laceration

c)Pelvic hematoma Explanation: A hematoma also can form deep in the pelvis where it is much more difficult to identify. The primary symptom is deep pain unrelieved by comfort measures or medication and accompanied by vital sign instability.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps- assisted birth. Maternal complications include tissue trauma, such as lacerations of the cervix, vagina, and perineum, hematoma, extension of episiotomy into the anus, hemorrhage, and infection.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which medication would be contraindicated in her case?

carboprost Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, misoprostol should not be given to women with active CVD, pulmonary or hepatic disease, and methylergonovine should not be given to a woman who is hypertensive.

Forces of contractions, mild asphyxia, increased intracranial pressure, and cold stress all play a role in the newborn transition by releasing which critical component?

catecholamines The physical forces of contractions at labor, mild asphyxia, increased intracranial pressure, and cold stress immediately experienced after birth lead to an increased release of catecholamines, which is critical for the changes involved in the transition to extrauterine life.

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?

cephalohematoma 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.

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilatation is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?

cesarean birth If the cause of the delay in dilatation is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD. pg 775

A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.

clay-colored stools tea-colored urine increased serum bilirubin levels

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which information would be important to collect first?

coagulation studies Coagulation studies should be prescribed immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status, although important, are not necessary emergently.

A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used.

commmitment, attachment, and preparation for an infant acquaintance with and increasing attachment to the infant moving toward a new normal routine achievement of the parental role Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.

A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client?

complications of a postterm pregnancy A postterm pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?

concentration of immature blood vessels

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?

conduction A conduction heat loss results from direct contact with an object that is cooler. p 850

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?

conduction Heat loss by conduction can occur when the nurse touches the newborn with cold hands. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with one another. Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not direct contact with the newborn. Evaporation involves the loss of heat when a liquid is converted to a vapor.

Which factors in a maternal birth record are risks for fetal growth restriction?

congenital malformations, infections, or placental insufficiency

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?

consistency, shape, and location Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus. pg 767

A newborn is challenged to maintain an adequate body temperature. If a baby is placed too close to a cold air vent, the nurse can assume that the infant will lose heat by which mechanism?

convection There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. 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. The cold air blowing on the infant's skin will cause heat loss.

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?

convection and evaporation 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 woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression Oligohydramnios and meconium staining of the amniotic fluid are common complications of postterm pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color?

creamy yellow If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

The nursing student demonstrates an understanding of dystocia with which of the following statements? a) "Dystocia is not diagnosed until after the delivery." b) "Dystocia cannot be diagnosed until just before delivery." c) "Dystocia is diagnosed at the start of labor." d) "Dystocia is diagnosed after labor has progressed for a time."

d) "Dystocia is diagnosed after labor has progressed for a time." Rationale: Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the patient and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

A woman is to undergo labor induction. The nurse determines that the woman most likely requires cervical ripening if her Bishop score is: a) 9 b) 7 c) 6 d) 5

d) 5 Rationale: A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client? a) Prepare the client for cesarean birth b) Prepare to administer oxytocin c) Darken the room lights d) Convert the birthing room to birth readiness before full dilatation is obtained

d) Convert the birthing room to birth readiness before full dilatation is obtained Rationale: Both grand multiparas (women who have given birth five or more times) and women with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even if a sudden birth should occur, it can be accomplished in a controlled surrounding. As the client is likely to give birth relatively quickly, there is no need for oxytocin or to darken the room lights. There is also no indication that cesarean birth will be necessary, particularly because all of the client's previous births were vaginal.

A client in the active phase of labor is diagnosed as having a protracted labor pattern. Which of the following would the nurse assess as indicative of a protracted labor pattern? a) Secondary arrest of cervical dilation b) Arrest of the descent of the fetal head c) Prolonged deceleration phase d) Delayed descent of the fetal head

d) Delayed descent of the fetal head Rationale: Protraction disorders are characterized by delayed descent of the fetal head and delayed cervical dilation. Prolonged deceleration phase, secondary arrest of cervical dilation, and arrest of the descent of the fetal head are characteristics of arrest disorder and not of protraction disorder.

A nurse working with a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10 hours ago. The report indicates an absence of the protein, which the nurse knows indicates: a) Delivery is likely within the next 2 weeks. b) Infection is present. c) No infection is present. d) Delivery is unlikely within the 2 next weeks.

d) Delivery is unlikely within the 2 next weeks. Rationale: Fetal fibronectin is a protein that helps the placenta and fetal membranes adhere to the uterus during pregnancy. A negative result (absence of fetal fibronectin) is a reliable indicator that delivery is unlikely within 2 weeks following the test. It does not diagnose infection.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Applying warm compresses b) Administering bromocriptine (Parlodel) c) Restricting fluids d) Applying ice

d)Applying ice Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids doesn't reduce engorgement and shouldn't be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.

Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth?

hemoglobin: 17.5 g/dL 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.

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa and abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.

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 The nurse should monitor the pulse and blood pressure frequently in the first 24 hours postpartum because the client is at greatest risk of hemorrhage. Hemorrhoids cause discomfort and contribute to constipation; this does not call for monitoring of pulse and blood pressure frequently. Increased coagulability causes increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-assisted births pose an increased risk for cervical laceration. None of these conditions require monitoring of pulse and blood pressure.

At birth, changes from fetal to newborn circulation must occur. What change causes the ductus arteriosus to close?

higher oxygen content of the circulating blood The first few breaths greatly increase the oxygen content of circulating blood. This chemical change (i.e., higher oxygen content of the blood) contributes to the closing of the ductus arteriosus, which eventually becomes a ligament.

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia. p. 850

Which factors should a nurse identify as some of the common etiologies of physical and psychological changes during the fourth stage of labor and postpartum? Select all that apply.

hormonal changes genetic predisposition sleep loss The nurse should identify hormonal changes, genetic predisposition, and sleep loss as some of the common etiologies of physical and psychological changes during the fourth stage of labor and postpartum. Nausea and psychological imbalance are not etiologies of physical and psychological changes during the fourth stage of labor and postpartum.

The nurse observes a newborn. He notes that the respiratory rate is 66, the newborn's nostrils flare out, and the newborn makes a grunting sound during respiration. What does the nurse conclude from these findings? The infant is:

in respiratory distress. The assessment findings discussed are signs of respiratory distress. An infant with a respiratory rate of greater than 60 with noise requires further assessment. All newborns burn brown fat to produce heat for their bodies. This is not something the nurse can assess. The scenario described does not indicate that the newborn is cold-stressed nor experiencing radiation heat loss.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?

inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? inadequate secretion of prolactin improper positioning of infant cracking of the nipple inability of infant to empty breasts

inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.

inability to concentrate loss of confidence decreased interest in life The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis

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 urinary retention 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.

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 urinary retention 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.

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?

intubation and suctioning of the trachea Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. The nurse should not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea. p 837

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness Jitteriness is evident with a newborn with hypoglycemia as well as poor feeding with feeble sucking. The newborn would have tachypnea. Jaundice is not part of the newborn hypoglycemic syndrome. Positive Moro reflex and palmar creases are normal. pg 840

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

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect?

laceration Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them?

laceration of the cervix There are four major causes of postpartum hemorrhage: uterine atony, inability of the uterus to contract effectively; lacerations to the uterus, cervix, vagina, or perineum; retained placenta; and disruption in maternal clotting mechanisms. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors.

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

A pregnant client is in labor. The nurse reviews a mother's prenatal history and finds that the client has diabetes mellitus. The nurse anticipates that the newborn is at risk for being

large-for-gestational-age.

The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production?

nonshivering thermogenesis The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. When the newborn is in a cold environment, the blood flow is increased through the brown fat, which warms the blood and in turn helps warm the infant.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm. dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

occiput posterior position A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor." pg 767

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

odor. The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.

Losing a newborn is perhaps one of the most difficult situations for a family. Which action by the nurse would be the most appropriate if a newborn dies?

offering mementos to the family of the newborn

To administer oxygen by bag and mask to a newborn, you would position the baby

on the back with the head slightly extended.

A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development?

paternal factors Fetal growth is dependent on genetic, placental, and maternal factors.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor?

placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/dL. Precipitous labor, less than 3 hours, and multiparity, more than three births closely spaced, place a woman at risk for postpartum hemorrhage.

A nurse is conducting a in-service education program for a group of nurses working in the postpartum unit about postpartal infection. The nurse determines that the teaching was successful when the group identifies which factor as contributing to the risk for infection postpartally?

placenta removed via manual extraction Manual removal of the placenta, a labor longer than 24 hours, a hemoglobin less than 10.5 mg/dL, and multiparity, such as more than three births closely spaced together, would place the woman at risk for postpartum infection.

A client is at 23 weeks' gestation and was admitted for induction and birth after noting the infant was an intrauterine fetal death. The client had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death?

placental abruption The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes or the possibility of preeclamsia. pg 784

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

placental factors Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as placental factors with abnormal umbilical cord insertion, chronic placental abruption, malformed and smaller placentas, with placental previa or placental insufficiency being the main placental causes. Blood group incompatibility, having many pregnancies, and being over the age of 30 will not cause an SGA infant.

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse performs which action to prevent prolapse or inversion of the uterus?

places a gloved hand just above the symphysis pubis The nurse can prevent prolapse or inversion of the uterus by placing a gloved hand just above the symphysis pubis that guards the uterus and prevents any downward displacement that may result in prolapse or inversion. To assess the client's rectus muscle, the nurse places the index and middle fingers across the muscle. Palpating the abdomen and feeling the uterine fundus or massaging the fundus carefully to expel any blood clots would be of no benefit in preventing prolapse or inversion of the uterus

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?

policies that discourage unwrapping and exploring the infant Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia Newborns born small for gestational age (SGA) are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age. Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy).

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?

polycythemia, probably due to chronic fetal hypoxia The small-for-gestational-age neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores.

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 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.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production?

prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production? estrogen oxytocin progesterone prolactin

prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.

A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:

respiratory distress. Ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation less than 87 %. These assessment findings do not indicate bronchial pneumonia respiratory alkalosis or cardiac distress at this time. p 846

All the options are signs of respiratory distress in the newborn except:

respiratory rate >50 breaths/minute. Coughing and sneezing are normal reflexes present in newborns. The expected respiratory rate of newborn is 30 to 60 breaths per minute. pg 569

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?

respiratory rate of 60 to 70 bpm

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?

respiratory rate of 60 to 70 bpm The nurse should identify respiratory complications such as tachypnea as a symptom of meconium aspiration in the newborn that results from presence of meconium in the amniotic fluid. Tachycardia, elevated bilirubin levels, and polycythemia are some of the common problems faced by an SGA newborn, but these are not related to meconium in the amniotic fluid.

When providing care for a postpartum client at a 6-week check up, which behavior would alert the nurse the client may have postpartum psychosis?

restless and agitated, concerned with self When a woman has postpartum psychosis the signs may vary, but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation.

The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 2-inch lochia stain. This amount should be documented as which type?

scant Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

What is the primary function of uterine contractions after birth of the infant and placenta?

seals off the blood vessels at the site of the placenta 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.

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?

second period of reactivity 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.

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur?

second stage of labor Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

A nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. This behavior can best be explained as:

self-quieting ability. Self-quieting ability refers to newborns' ability to quiet and comfort themselves. Assisting parents to identify consoling behaviors also helps. The sleep state is noted as an infant becoming drowsy and less attentive to the parents and his surroundings. Social behaviors are things such as cuddling and snuggling into the arms of the parents when the newborn is held. Motor maturity refers to posture, tone, coordination, and movements of the newborn.

A postpartum woman is diagnosed as having endometritis. Which position would the nurse expect to place her in based on this diagnosis?

semi-Fowler's A semi-Fowler's position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would be contraindicated.

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 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.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional sign should the nurse consider as an indication of respiratory distress syndrome (RDS) in the newborn?

sternal retraction The nurse should consider sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather, a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration. pg 845

A nurse is caring for a client in the postpartum period. The nurse observes that distention of the abdominal muscles during pregnancy has resulted in separation of the rectus muscles. What intervention should the nurse perform to assist in healing the distended abdominal muscles?

suggesting proper exercise The nurse should suggest proper exercise to the client to heal the distended abdominal muscles. Application of warm compresses, application of moist heat, and massaging the muscles gently are not suggested for distended abdominal muscles

Which factor might result in a decreased supply of breast milk in a postpartum client?

supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.

A nurse working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing?

surfactant Surfactant is a protein that keeps small air sacs in the lungs from collapsing. Its use was introduced in 1990 and continues today, especially for premature babies and those who have respiratory distress syndrome. The other medications are not given to help premature babies breathe. pg 568

The mother has given birth to a premature infant at 30 weeks. To ensure the alveoli can function properly, the infant needs to be evaluated for:

surfactant. Surfactant is a surface tension-reducing lipoprotein found in the newborn's lungs that prevents alveolar collapse at the end of expiration and loss of lung volume. Surfactant provides the lung stability needed for gas exchange. Oxygen, hematocrit, and blood flow are unrelated.

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply.

swaddling the newborn closely offering a pacifier prior to a procedure encouraging kangaroo care during procedures Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries; using gentle handling, rocking, caressing, and cuddling; encouraging kangaroo care during procedures; and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. pg 855

A newborn infant born by a cesarean birth is experiencing a common problem seen in these type of births. What finding would the nurse anticipate in an infant following a cesarean birth?

tachypnea The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur. pg 568

A nurse is assessing a newborn who is about 8 hours old. The nurse suspects that the newborn may be experiencing cold stress based on which findings? Select all that apply.

tachypnea lethargy hypotonia Cold stress is excessive heat loss that requires a newborn to use compensatory mechanisms (such as nonshivering thermogenesis and tachypnea) to maintain core body temperature (Davidson, 2014). The consequences of cold stress can be quite severe. As the body temperature decreases, the newborn becomes less active, lethargic, hypotonic, and weaker. All newborns are at risk for cold stress, particularly within the first 12 hours of life. Jaundice and hypoglycemia may result from cold stress if not reversed.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. 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.

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. 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.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?

thromboembolic disorder of the lower extremities Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted.

A client develops mastitis 3 weeks after giving birth. What part of self-care does the nurse tell her is most important?

to breastfeed or otherwise empty her breasts every 1 to 2 hours Mastitis treatment involves complete removal of the milk from the breast as often as possible but no longer than a 3 hour time span and antibiotic therapy. It is most important to have the women keep the breast empty to prevent further stasis of milk ducts and worsening mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care.

The nurse encourages a mother to rock, sing, and talk to her premature newborn. What is the purpose of these activities with the infant?

to develop trust in people

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed?

tocolytic therapy Tocolytic therapy is most likely prescribed if preterm labor occurs before the 34th week of gestation in an attempt to delay birth and thereby reduce the severity of respiratory distress syndrome and other complications associated with prematurity. pg 769

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

touching Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?

touching Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider? writing pictures touching recognizing the meaning of words

touching Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary tract infection postpartum diuresis trauma to pelvic muscles urinary overflow

trauma to pelvic muscles The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated; and abundant vernix caseosa. pg 841

Postpartum infection is one event that is known to impede the recovery process of a new mother. Which characteristics after birth make a woman more susceptible to infection? Select all that apply

urinary stasis denuded endometrial arteries episiotomy 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. 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.

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition? stress incontinence urinary tract infection loss of pelvic muscle tone increased urine output

urinary tract infection The nurse would need to monitor the client for signs and symptoms of a urinary tract infection, a risk associated with catheterization. Stress incontinence is caused due to loss of pelvic muscle tone after birth. Increased urinary output is observed in diuresis. Catheterization does not cause loss of pelvic muscle tone, increased urine output, or stress incontinence.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.

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 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 Hispanic client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client?

uterine atony Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario

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? postpartum diaphoresis urinary tract infection uterine atony urinary retention

uterine atony 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 postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

uterine infection prolonged labor hydramnios Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?

uterine rupture The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?

uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. 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 completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature?

increased amounts of vernix Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between EDC and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.

When assessing a postpartum woman, which finding would be most significant in identifying possible postpartum hemorrhage?

increased heart rate Tachycardia in the postpartum woman warrants further investigation. Typically the postpartum woman is bradycardic for the first 2 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.

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which possible effect?

interference with the maternal-newborn attachment process The nurse would include information that maternal postpartum complications affect not only the health status of the woman, but also that of the newborn by potentially interfering with the maternal-newborn attachment process. Furthermore, they can disrupt the dynamics of the entire family, with health-related, fiscal, and emotional effects and costs. Maternal postpartum complications are not known to result in ineffective breastfeeding, delayed development of the newborn, or altered maternal hormonal function.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? lochia serosa diaphoresis edematous vagina uterus 1 cm below umbilicus

uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. 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 postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:

very low birth weight.

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:

very low birth weight. A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight.

The nurse assesses a postpartum woman for thromboembolism based on the understanding that her risk is increased because of which factor?

vessel damage during birth A woman's risk for thromboembolism increases due to her hypercoagulable state, vessel damage during birth, and immobility. The increase in white blood cell count is unrelated to her risk for thromboembolism. Coagulation factors remain elevated for 2 to 3 weeks postpartum. An episiotomy is not a risk factor for thromboembolism.

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.

yellowish gold color stringy to pasty consistency The stools of a breastfed newborn are yellowish gold in color. They are not firm in shape or solid. The smell is usually sour. A formula-fed infant's stools are formed in consistency, whereas a breastfed infant's stools are stringy to pasty in consistency. pg 577

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?

yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?

yellowy mustard color with seedy appearance The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. If breastfed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer. The neonate's stool should not appear brownish-black and mucous-like.

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000 mL Postpartum hemorrhage is defined as blood loss of 500 mL or more after a vaginal birth and 1000 ml or more after a cesarean birth.

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn?

Observe for clinical signs of cold stress such as weak cry.

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. The patient is stable at the time of admission. The priority nursing assessment for the client is for: a) Fetal heart tones. b) Signs of shock. c) Infection. d) Uterine stabilization

a) Fetal heart tones. Rationale: When a patient is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. Options C and D are not a higher priority than fetal heart tones.

The nurse is monitoring a patient in labor who has had a previous cesarean section and is trying a vaginal birth with epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The patient reports severe pain in her abdomen and shoulder. What should the nurse prepare to do? a) Prepare the patient for a cesarean section. b) Place the patient in a knee-chest position. c) Bolus the patient with another dose of medication through the epidural. d) Turn the patient on her left side.

a) Prepare the patient for a cesarean section. Rationale: The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean delivery.

The second-year nursing student taking an obstetrics course correctly attributes which of the following to the term dystocia? (Check all that apply.) a) Progress of labor deviates from normal. b) Labor is slow. c) Labor progresses normally. d) Labor is fast.

a) Progress of labor deviates from normal. b) Labor is slow. Rationale: Dystocia is said to exist when the progress of labor deviates from normal and is slow.

Which intervention would be most appropriate for the woman experiencing dystocia related to problems involving the psyche? a) Providing a comfortable environment with dim lighting b) Preparing the woman for an amniotomy c) Administering oxytocin d) Encouraging the woman to assume a hands-and-knees position

a) Providing a comfortable environment with dim lighting Rationale: Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). An amniotomy may be used with hypertonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

The nurse would prepare a client for amnioinfusion when which of the following occurs? a) Severe variable decelerations are due to cord compression b) Maternal pushing is compromised due to anesthesia c) The fetus shows non-reassuring fetal heart rate patterns d) Fetal presenting part fails to rotate fully and descend in the pelvis

a) Severe variable decelerations are due to cord compression Rationale: Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, non-reassuring fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

Which of the following would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? a) Activated partial thromboplastin time b) Prothrombin time c) Platelet level d) Fibrinogen level

a)Activated partial thromboplastin time Explanation: The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching?

"Use talc powders to prevent diaper rash."

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?

108 beats/minute

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?

12 hours

The heart rate of the newborn in the first few minutes after birth will be in which range?

120 to 180 bpm During the first few minutes after birth, the newborn's heart rate is approximately 120 to 180 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm pg 565

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?

"I didn't realize all that went into being a dad. I wasn't prepared for this." 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 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 things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. 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.

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

"I didn't realize all that went into being a dad. I wasn't prepared for this." 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 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 things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. 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.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?

"I only eat a low-fiber diet." Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?

"I should brush my teeth vigorously to stimulate the gums." The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.

A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: "If you are breast-feeding, that will help make your uterus contract and get smaller." "There is really nothing you can do to speed along the progress, so just be patient." "Eating a large amount of protein and carbohydrates will help make the uterus contract." "I would recommend that you rest for a few days to allow your body to heal and get back to normal."

"If you are breast-feeding, that will help make your uterus contract and get smaller." There are several things that a new mother can do to assist in uterine involution. The most well known one is breast-feeding the infant. Whenever a new mother breast-feeds her infant, it stimulates the release of oxytocin, which stimulates the uterus to contract. The mother is also advised to eat a well-balanced diet and ambulate early in the postpartum period.

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?

"It might take up to a week for your bowels return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas to gain additional information. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the healthcare provider is not necessary, and this statement could add to the client's currrent concern.

A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase?

"It sounded like you had quite a time getting here. Would you like to continue your story?" The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.

A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? "It sounded like you had quite a time getting here. Would you like to continue your story?" "If you plan to breast-feed, you need to calm down." "You have a beautiful baby, why worry about that now?" "I need to assess your fundus now."

"It sounded like you had quite a time getting here. Would you like to continue your story?" The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to."

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A nurse is making an initial call on a new mother who gave birth to her third baby five days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

A woman comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." The woman is dressed in hospital scrub attire but has no name badge showing. What is the best response by the nurse caring for the baby?

"May I see your identification, please?"

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG." The preterm newborn's immune system is very immature, increasing his or her susceptibility to infections. A deficiency of IgG may occur because transplacental transfer does not occur until after 34 weeks' gestation. This protection is lacking if the baby was born before this time. Preterm newborns have an impaired ability to manufacture antibodies to fight infection if they were exposed to pathogens during the birth process. The preterm newborn's thin skin and fragile blood vessels provide a limited protective barrier, adding to the increased risk for infection. Anticipating and preventing infections is the goal with frequent hand washing while caring for them the gold standard. Breastfeeding will eventually establish some protective mechanisms. pg 843

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs. pg 840

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." The nurse should explain to the client that lochia rubra is a deep red mixture of mucus, tissue debris, and blood. Discharge consisting of leukocytes, decidual tissue, RBCs, and serous fluid is called lochia serosa. Discharge consisting of only RBCs and leukocytes is blood. Discharge consisting of leukocytes and decidual tissue is called lochia alba.

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? "It takes a while to get your body back to its normal function after having a baby." "This is entirely normal, and many women go through it. It just takes time." "You might try using a water-soluble lubricant to ease the discomfort." "Try doing Kegel exercises to get your pelvic muscles back in shape."

"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

"You should be seen by your healthcare provider if you have blurred vision." The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

A premature newborn has repeated blood work drawn by heel prick. The mother asks the nurse, "Does my baby feel the pain from all these procedures?" What is the nurse's best response?

"Your baby is more sensitive to the pain than adults are."

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." Postpartum diuresis is due to the buildup and retention of extra fluids during pregnancy. Bruising and swelling of the perineum, swelling of tissues surrounding the urinary meatus, and decreased bladder tone due to anesthesia cause urinary retention.

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? "Anesthesia causes decreased bladder tone, which causes you to urinate more frequently." "Larger than normal amounts of urine frequently occurs due to swelling of tissues surrounding the urinary meatus." "Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." "Bruising and swelling of the perineum often causes excessive urination."

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." Postpartum diuresis is due to the buildup and retention of extra fluids during pregnancy. Bruising and swelling of the perineum, swelling of tissues surrounding the urinary meatus, and decreased bladder tone due to anesthesia cause urinary retention.

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity?

100 mm Hg

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

100.4° F (38° C) A temperature over 100.4° F (38° C) past the first day postpartum is suggestive of infection.

A nurse is caring for a postpartum client who has a temperature. Which temperature protocols would the nurse use to indicate a possible infection?

100.5º F (38.1º C) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4º F (38º C) on 2 postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response? Ask the client why she does not want to go home. Inform the primary care provider that the client does not want to go home. Tell the client that she must go home as per hospital policy. Ask the client if she has any support in the home.

Ask the client why she does not want to go home. It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. Open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address concerns appropriately. Asking about supports at home implies that the nurse has made assumptions about why the client may not want to go home. Informing the care provider or telling the client that discharge is hospital policy is not appropriate at this time because the nurse has not addressed the underlying reason for the client's comment. The client may have safety-related concerns, undisclosed fears, or a need for increased support before discharge. It is imperative that the nurse not make assumptions but further explore concerns.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor. In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

Upon assessment, the nurse notes a postpartum client has increased vaginal bleeding. The client had a forceps birth that resulted in lacerations 4 hours ago. What should the nurse do next?

Assess for uterine contractions. The nurse needs to identify whether the bleeding is from lacerations or uterine atony. This can be done by looking for a well contracted uterus with bright-red vaginal bleeding. Lacerations commonly occur during forceps birth. In subinvolution of the uterus, there is inadequate contraction, resulting in bleeding. A boggy uterus with vaginal bleeding is seen in uterine atony. Once the nurse knows the cause of the bleeding, the condition can be treated.

A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply.

Assess the axillary temperature every hour. Review maternal history. Assess environment for sources of heat loss. Encourage skin-to-skin contact. Proper care to promote thermoregulation include assessing the axillary temperature every hour, reviewing the maternal history to identify risk factors contributing to problem, assessing the environment for sources of heat loss, avoiding bathing and exposing newborn to prevent cold stress, and encouraging kangaroo care (mother or father holds preterm infant underneath clothing skin-to-skin and upright between breasts) to provide warmth.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize?

Assess the newborn for signs of respiratory distress.

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

Avoid products containing aspirin. The nurse should caution the client to avoid products containing aspirin, which inhibits the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. The nurse should not instruct the client to refrain from performing any leg exercises; instead, the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises.

A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply.

There is a family history of hemophilia. The infant is at 33 weeks' gestation.

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant?

Dry the infant, stimulate the infant, and keep the infant warm.

The nurse is preparing a client for discharge and notes an order for rubella vaccine. Which teaching should the nurse prioritize? May experience rash, sore throat, headache, or general malaise within 2 to 4 weeks of the injection Advise the client that the vaccine is excreted in breast milk. Will prevent hemolytic disease of the infant in next pregnancy Do not to attempt another pregnancy for at least 3 months.

Do not to attempt another pregnancy for at least 3 months. The nurse should prioritize the fact that after the immunization, she needs to wait for at least 3 months before attempting to get pregnant again, if desired, so the fetus will not be exposed to the rubella vaccination. The rubella vaccine is a live virus and is considered teratogenic. The other choices are not priorities. Inform the breastfeeding woman that the rubella vaccine crosses over into the breast milk. The newborn benefits from short-term immunity but may become flushed, fussy, or develop a slight rash. Suggest that the woman speak to the pediatrician if she has concerns. The client may also experience a rash, sore throat, headache, and general malaise within 2 to 4 weeks after the injection. The nurse would not advise the new mother that the immunization will prevent hemolytic disease of the infant in her next pregnancy; this is incorrect information.

A nurse is caring for a 3-hour-old newborn boy. The nurse makes the initial assessment and finds the following: respiratory rate 30 bpm, BP 60/40 mm/Hg, heart rate 155 bpm, axillary temperature 98.2° F (36.8° C). The nurse assesses that the newborn is in a state of quiet alert. What should the nurse do?

Document the data. The normal respiratory rate is 30 to 60 breaths per minute and should be counted for a full minute when the infant is quiet. A newborn starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 bpm). Normal temperature range is between 97.7 ° F (36.5 ° C) and 99.5 ° F (37.5 ° C).

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?

Document the lochia as scant. "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.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf. A positive Homans' sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for reddness and warmth and if she has increased pain when she ambulates or bears weight.

What is the correct sequence of events in a neonatal resuscitation?

Dry the infant, establish an airway, expand the lungs, and initiate ventilation.

The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? Put on the call button to summon help Administer oxytocics to prevent uterine atony Teach the woman to perform periodic self-fundal massage Gently massage the fundus until it tones up

Gently massage the fundus until it tones up After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the patient. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.

A perinatal nurse is providing care for a large for gestational age neonate admitted to the observational unit after a complicated vaginal birth resulting in shoulder dystocia. Which assessment would be a priority for the nurse to perform?

Moro assessment

Healthy bonding behaviors are important to note when the nurse is assessing the new family. What would the nurse consider a warning sign that the mother and infant were not attaching as they should?

Mother states she wanted a boy this time, not another girl. It is important to differentiate between a new parent who is nervous and anxious about her new role and one who is rejecting her parenting role. Warning signals of poor attachment include turning away from the newborn, refusing or neglecting to provide care, and disengagement from the newborn.

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 Chest retractions

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?

Newborns have the ability to focus only on objects in close proximity. In regards to vision the newborn has the ability to focus on objects only in close proximity (8 to 30 cm away) and tracks objects in midline or beyond. Vision is the least mature sense at birth. pg 579

A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborn's temperature between 97.7° F and 99.5° F (36.5° C and 37.5° C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range?

Place the newborn skin-to-skin with the mother. The nurse should place the newborn skin-to-skin with mother. This is the best way to help maintain the newborn's temperature as well as promoting breastfeeding and bonding between the mother and newborn. The nurse can weigh the infant as long as a warmed cover is placed on the scale. The stethoscope should be warmed before it makes contact with the infant's skin, rather than using the stethoscope over the garment because it may obscure the reading. The newborn's crib should not be placed close to the outer walls in the room to prevent heat loss through radiation.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position. When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation. p 848

A nurse is assessing the temperature of a newborn using a skin temperature probe. Which point should the nurse keep in mind while taking the newborn's temperature?

Place the temperature probe over the liver. The nurse should place the temperature probe over the newborn's liver. Skin temperature probes should not be placed over a bony area like the forehead or used in an open bassinet with no heat source. The newborn should be in a supine or side-lying position.

A laboring mother requests that she be allowed to participate in kangaroo care following delivery. The nurse understands that this involves what action?

Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket.

A newborn weighed 7 lb, 3 oz (3220 g) at birth. Based on this birth weight, which procedure would be necessary for you to carry out?

Plotting his weight on a gestational age graph

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

RDS is caused by a lack of alveolar surfactant. Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest X-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute). p 842

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer?

Radiation

The nurse is teaching discharge instructions to the young parents of a healthy newborn boy, whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?

Redness at the base of the umbilical cord

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The rooting reflex is an example of a newborn's sense of touch. The fetus can hear in utero.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed. Typically newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. However, this preterm newborn has an inadequate supply of brown fat because he or she left the uterus early before the supply was adequate. Conduction heat loss allows an increased transfer of heat from their bodies to the environment, but there is nothing to substantiate conduction heat loss. Axillary temperatures are accurate and the mode of taking temperatures for neonates.

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

The tint is due to jaundice

A client in the first stage of labor is diagnosed with dystocia involving the powers of labor. What would the nurse identify as the problem?

Uterine contractions are too weak or uncoordinated. When there are problems with the powers causing dystocia during the first stage of labor, the uterine contractions are too weak or uncoordinated to cause adequate cervical effacement and dilatation. Contractions are insufficient to cause fetal descent; the fetus being in a different position or presentation, and pelvis being either android type or platypelloid type are not the results of dystocia. During the second stage of labor, the nurse should observe if the contractions and the pushing are insufficient to cause descent of the fetus. A fetus that is in a different position or presentation is a problem with the passenger. A pelvis that is either android type or platypelloid type is a problem with the passageway and is not related to dystocia.

The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartal blues? a 29-year-old mother who has lots of family visiting and offering to help her with meals and cleaning for the next few months a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding an 18-year-old mother who is currently holding her baby and looking face-to-face at the baby without saying a word a 38-year-old G1 P1 who is constantly holding the baby and touching the baby's hands and fingers

a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding During the postpartal period many women experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The teenage mom is holding the baby in en face position, which is normal. The 29-year-old woman has a supportive, close family and there is no indication she is experiencing postpartal blues. The 38-year old-mother is in a normal phase after birth and is exploring the infant's body, a part of the taking-in phase that occurs 1 to 3 days after birth.

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 A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a scant amount of lochia alba a moderate amount of lochia rubra a scant amount of lochia serosa a moderate amount of lochia alba

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

A client and her infant are being discharged home after an unplanned cesarean birth. The nurse explains to her that she is at a higher risk for postpartum infection than most clients. What is the major risk factor for a postpartum infection?

a nonelective cesarean birth The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity.

Bonding between a mother and her infant can be defined how?

a process of developing an attachment and becoming acquainted with each other 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 year-long process, and the family growing closer together after the birth of a new baby is not bonding.

Which of the following would be appropriate for the use of low forceps? a) The leading point of fetal skull is at or above station +2, not on the pelvic floor b) The fetal head is engaged but the leading point of the skull is less than +2 c) The fetal skull has reached the pelvic floor, with the fetal head at the perineum d) The fetal scalp is visible at the introitus without spreading the labia

a) The leading point of fetal skull is at or above station +2, not on the pelvic floor Rationale: Low forceps are applied when the leading point of the fetal skull is at or above station +2 and not on the pelvic floor. Outlet forceps, and not low forceps, are applied when the fetal skull has reached the pelvic floor, with the fetal head at the perineum and the fetal scalp visible at the introitus without spreading the labia. Mid forceps, and not low forceps, are applied when the fetal head is engaged but the leading point of the skull is less than +2.

A client in the first stage of labor is diagnosed with dystocia involving the powers of labor. Which of the following would the nurse identify as the problem? a) Uterine contractions are too weak or uncoordinated b) Contractions are insufficient to cause fetus descent c) Fetus is in a different position or presentation d) Pelvis is either android type or platypelloid type

a) Uterine contractions are too weak or uncoordinated Rationale: When there are problems with the powers causing dystocia during the first stage of labor, the uterine contractions are too weak or uncoordinated to cause adequate cervical effacement and dilatation. Contractions are insufficient to cause fetal descent; the fetus being in a different position or presentation, and pelvis being either android type or platypelloid type are not the results of dystocia. During the second stage of labor, the nurse should observe if the contractions and the pushing are insufficient to cause descent of the fetus. A fetus that is in a different position or presentation is a problem with the passenger. A pelvis that is either android type or platypelloid type is a problem with the passageway and is not related to dystocia.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. Your best action would be to a) assess the rate of flow of the oxytocin infusion. b) assess her vaginally for full dilation. c) administer oral orange juice for added potassium. d) instruct her to breathe in and out rapidly.

a) assess the rate of flow of the oxytocin infusion. Rationale: A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

The nursing student correctly identifies which of the following as risk factors for developing dystocia? (Check all that apply.) a) excessive analgesia b) maternal exhaustion c) maternal diabetes d) high fetal station at complete cervical dilation e) multiple gestation f) epidurals g) shoulder dystocia

a) excessive analgesia b) maternal exhaustion d) high fetal station at complete cervical dilation e) multiple gestation f) epidurals g) shoulder dystocia Rationale: Early identification and prompt interventions for dystocia are essential to minimize risk to the woman and fetus. Factors associated with increased risk for dystocia include epidurals, excessive analgesia, multiple gestations, maternal exhaustion, ineffetive pushing technique, longer first stage of labor, fetal birth weight, maternal age of >35, ineffective uterine contractions, and high fetal station at complete cervical dilation.

A nursing instructor is teaching students about fetal presentations during delivery. The most common cause for increased incidence of shoulder dystocia is: a) increasing birth weight b) increased number of overall pregnancies c) poor quality of prenatal care d) longer lengths of labor

a) increasing birth weight Rationale: Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in up to 2% of vaginal births.

A nurse is preparing to teach a class to pregnant women about the signs of preterm labor and what to do if these occur. Which of the following should the nurse include in the presentation? (Select all that apply.) a) leaking of fluid from the vagina b) uterine contractions, cramping, low back pain c) feeling of pelvic pressure or fullness d) feelings of stress e) nausea, vomiting, and diarrhea f) increase in vaginal discharge

a) leaking of fluid from the vagina b) uterine contractions, cramping, low back pain c) feeling of pelvic pressure or fullness e) nausea, vomiting, and diarrhea f) increase in vaginal discharge Rationale: Signs and symptoms of preterm labor include uterine contractions, cramping, or low back pain; feeling of pelvic pressure or fullness; increased vaginal discharge; nausea, vomiting, and diarrhea; and leaking of fluid from the vagina.

A nursing instructor teaching about risk factors associated with preterm labor includes which of the following demographic and lifestyle issues? (Select all that apply.) a) smoking b) infection c) hypertension d) low socioeconomic status e) high level of stress f) alcohol use

a) smoking d) low socioeconomic status e) high level of stress f) alcohol use Rationale: Demographic and lifestyle risk factors associated with preterm labor are extremes of maternal age (younger than 17 years or older than 35 years), low socioeconoomic status, smoking, alcohol or drug use, high levels of stress, and long working hours. Infection and hypertension are medical risk factors and not demographic or lifestyle factors.

Which woman should you suspect of having endometritis? a) A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. b) A woman with a history of infection and smoking who develops a temperature of 101 degrees on the fourth postpartum day. She reports severe perineal pain. The edges of the episiotomy have separated. c) An obese woman who has a temperature of 100.4 degrees at 12 hours after delivery. Her lochia is moderate; vaginal cultures are negative. d) A woman with PROM before delivery complains of severe burning with urination, malaise and severe temperature spikes on the seventh postpartum day. WBC is 21,850cells/mm3; temperature is 101 degrees; and her skin is pale and clammy.

a)A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. Explanation: Endometritis is an infection of the endometrium of the uterus. The woman has an very elevated temp greater than 24 hours after delivery and high WBC. She would be treated for infection and monitored. Therefore options B, C, and D are incorrect.

You are conducting discharge teaching with a postpartum woman. What would be an important instruction for this patient? a) Call her caregiver if lochia moves from serosa to rubra. b) Call her caregiver if lochia moves from rubra to serosa. c) Call her caregiver if lochia moves from serosa to alba. d) Call her caregiver if amount of lochia decreases.

a)Call her caregiver if lochia moves from serosa to rubra. Explanation: Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, patient education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary-care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

It is discovered that a new mother has developed a puerperal infection. Which of the following is the most likely expected outcome that the nurse will identify for this patient related to this condition? a) Client's temperature remains below 100.4° F or 38° C orally b) Fundus remains firm and midline with progressive descent c) Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour d) Client maintains a urinary output greater than 30 mL per hour

a)Client's temperature remains below 100.4° F or 38° C orally Explanation: As fever would accompany a puerperal infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to puerperal infection as does the reduced temperature.

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? a) Endometritis b) Episiotomy infection c) Mastitis d) Subinvolution

a)Endometritis Explanation: The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.4°C], possibly as high as 104°F [40°C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absent.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse most likely expect the culture to reveal? a) Escherichia coli b) Staphylococcus aureus c) Gardenerella vaginalis d) Klebsiella pneumoniae

a)Escherichia coli Explanation: E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of metritis, but some species of Klebsiella may cause urinary tract infections.

A 35-year-old G2, P2 client presents to her postpartum appointment with vague complaints. The nurse suspects postpartum depression after the client expresses all except which of the following? a)Feels like eating all the time b)Change in sleep c)Appears detached from infant d)Lack of energy and motivation

a)Feels like eating all the time Explanation: Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed, cry a lot, exhibit a lack of energy and motivation, experience a lack of pleasure, changes in appetite, sleep, or weight, withdraw from friends and family, feel negatively toward her baby, or shows lack of interest in her baby.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which of the following medications would be contraindicated in her case? a)Hemabate b)Cytotec c)Methergine d)Pitocin

a)Hemabate Explanation: Hemabate is contraindicated with asthma due to the risk of bronchial spasms. Pitocin should be given undiluted as a bolus injection, Cytotec should not be given to women with active CVD, pulmonary or hepatic disease, and Methergine should not be given to a woman who is hypertensive.

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? a) Obtain a clean-catch urine specimen b) Administer amoxicillin, as prescribed c) Encourage her to drink large amounts of fluid d) Suggest that she take an oral analgesic

a)Obtain a clean-catch urine specimen Explanation: The client in this scenario shows classic signs of a urinary tract infection. The priority nursing action at this point is to obtain a clean-catch urine specimen to confirm the infection. The other answers are therapeutic management interventions that would take place after confirmation of the infection via the clean-catch urine specimen.

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which of the following is the most likely nursing diagnosis for this patient? a) Risk for fatigue related to chronic bleeding due to subinvolution b) Risk for infection related to microorganism invasion of episiotomy c) Risk for impaired breastfeeding related to development of mastitis d) Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis

a)Risk for fatigue related to chronic bleeding due to subinvolution Explanation: Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which of the following primary conditions? (Select all that apply.) a)Septicemia b)Abruptio placenta c)Isoimmunization d)Ectopic pregnancy e)Severe preeclampsia

a)Septicemia b)Abruptio placenta e)Severe preeclampsia Explanation: DIC is always a secondary diagnosis that occurs as a complication of abruptio placenta, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, severe preeclampsia, HELLP syndrome, septicemia, and hemorrhage.

Which of the following interventions would be most important when caring for the client with breech presentation confirmed by ultrasound? a) Noting the space at the maternal umbilicus b) Continuing to monitor maternal and fetal status c) Applying suprapubic pressure against the fetal back d) Auscultating the fetal heart rate at the level of the umbilicus

b) Continuing to monitor maternal and fetal status Rationale: Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.

You assess that the fetus of a woman is in an occiput posterior position. Which of the following identifies the way you would expect her labor to differ from others? a) Need to have the baby manually rotated. b) Experience of additional back pain. c) Shorter dilatational stage of labor. d) Necessity for vacuum extraction for delivery.

b) Experience of additional back pain. Rationale: Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction delivery.

At the hospital, a client is attached to the fetal monitor for uterine rupture. The nurse would assess for which pattern indicating change in the uterus impacting the fetus? a) Variable decelerations. b) Late decelerations. c) Mild decelerations. d) Early decelerations.

b) Late decelerations. Rationale: When the fetus is being deprived of oxygen the fetus will demonstrated late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.

A laboring patient has been pushing without delivering the fetal shoulders. The physician determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the delivery? a) Lamaze position b) McRobert's maneuver c) Fundal pressure d) Positioning the woman prone

b) McRobert's maneuver Rationale: The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the patient in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the physician informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? a) Anterior fetal position b) Transverse lie c) Cephalic presentation d) Occipitoposterior position

b) Transverse lie Rationale: A transverse lie, in which the fetus is more horizontal than vertical, occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelves.

A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which of the following tests should the student include? (Select all that apply.) a) thyroid level b) U/A c) CBC d) arterial blood gases e) amniotic fluid analysis

b) U/A c) CBC e) amniotic fluid analysis Rationale: Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis.

A woman experiences an amniotic fluid embolism as the placenta is delivered. Your first action would be to a) increase her intravenous fluid infusion rate. b) administer oxygen by mask. c) put firm pressure on the fundus of her uterus. d) tell the woman to take short, catchy breaths.

b) administer oxygen by mask. Rationale: An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

A nursing instructor highlights risk factors associated with preterm labor that include which of the following? (Select all that apply.) a) weight of pregnant mother b) current multiple gestation pregnancy c) history of previous preterm birth d) weight of fetus e) uterine or cervical abnormalities

b) current multiple gestation pregnancy c) history of previous preterm birth e) uterine or cervical abnormalities Rationale: The top risk factors for preterm labor include history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities. The weight of the fetus or mother does not cause preterm labor.

A nursing student correctly identifies the most desirable position to promote an easy delivery as which of the following? a) breech b) occiput anterior c) face and brow d) shoulder dystocia

b) occiput anterior Rationale: Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

A woman you are caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. Your best response would be that a) hypotonic contractions of this kind will strengthen by themselves. b) she needs to rest because her contractions are hypertonic. c) walking around will make her contractions more regular. d) her physician will order oxytocin to strengthen contractions.

b) she needs to rest because her contractions are hypertonic. Rationale: These contractions appear to be hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest is effective in helping contractions become more productive.

After teaching a class on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states: a)"Using passive range-of-motion exercises in bed sounds easy enough." b)"At least, I don't have to give up smoking for this one." c)"He has to do the deep breathing exercises with me." d)"I can drink more, so I don't get dehydrated."

b)"At least, I don't have to give up smoking for this one." Explanation: Preventing thrombotic conditions is an important aspect of postpartum care and proper nursing management. There are many simple measures that can be utilized, to include encouraging leg exercises and walking; using intermittent sequential compression devices; stopping smoking to reduce or prevent vascular vasoconstriction; using compression stockings; performing passive range-of-motion exercises while in bed; using postoperative deep breathing exercises to improve venous return; and increasing fluid intake to prevent dehydration.

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a) "Postpartum blues usually resolves by the 4th or 5th postpartum day." b) "Postpartum depression develops gradually, appearing within the first 6 weeks." c) "Postpartum psychosis usually appears soon after the woman comes home." d) "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."

b)"Postpartum depression develops gradually, appearing within the first 6 weeks." Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy

When treating a postpartum woman for hemorrhage, the nurse will prepare the client for a blood transfusion once the estimates of blood loss reach which level? a)1,000mL b)1,500mL c)1,750mL d)1,250mL

b)1,500mL Explanation: Once estimates of blood loss reach 1,500 mL, transfusion of blood products should be instituted immediately.

On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 99.6°F (37.5°C) b) 100.4°F (38°C) c) 102.4°F (39.1°C) d) 104.2°F (40.1°C)

b)100.4°F (38°C) Explanation: A temperature over 100.4°F (38°C) past the first day postpartum is suggestive of infection.

Which of the following behaviors exhibited by a 4-hour postpartum woman requires further interventions by the nurse? a) Returns her son to the nursery because of fatigue. b) Absent verbalization about the birthing process. c) Cuddles her son close to her while feeding. d) Tells visitors about her son and the labor.

b)Absent verbalization about the birthing process. Explanation: After delivery the woman would be excited and interested in the delivery and the infant. A woman may be tired and to ask for sleep is also expected, unexpected is the absent verbalization of the activities and birth. Therefore options A, C, and D are incorrect answers.

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication? a) Non-steroidal inflammatory b) Anticoagulants c) Narcotic analgesics d) Beta blockers

b)Anticoagulants Explanation: Anticoagulant therapy is used as the primary treatment option for DVT. This makes options A, C, and D incorrect.

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this? a) Ask her to raise her foot and draw a circle. b) Dorsiflex her right foot and ask if she has pain in her calf. c) Bend her knee and palpate her calf for pain. d) Blanch a toe and count the seconds it takes to color again.

b)Dorsiflex her right foot and ask if she has pain in her calf. Explanation: A Homans' sign (pain in the calf on dorsiflexion of the foot) is a common assessment for thrombophlebitis in conjunction with assessing for edema and calf redness. Having her raise her foot and draw a circle would not be an assessment for thrombophlebitis in her leg, nor would assessing capillary refill in a toe.

The nurse is assisting a client in completing the Postpartum Depression Screening Scale tool to assess for postpartum depression. Which of the following is least likely to be screened with this tool? a)Emotional liability b)Family and social support system c)Guilt d)Cognitive impairment

b)Family and social support system Explanation: The Postpartum Depression Screening Scale is divided into seven conceptual domains: anxiety/insecurity; sleep/eating disturbance/ emotional liability; loss of self-esteem; guilt/shame/ cognitive impairment; and suicidal thoughts.

About 10 days following birth, a new mother visits her physician with localized symptoms of redness, swelling, warmth, and a hard inflamed vessel in one leg. The nurse should suspect which of the following conditions? a) Subinvolution b) Femoral thrombophlebitis c) Mastitis d) Uterine atony

b)Femoral thrombophlebitis Explanation: A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge.

In preparing for a class in teaching women and their partners, which of the following would be the most important to emphasize as helping to prevent postpartum complications? a)Adequate follow-up with their health care provider b)Handwashing c)Ensure proper hydration d)Limiting contact with outsiders for the first week

b)Handwashing Explanation: Stressing proper handwashing, especially after perineal care and before and after breast-feeding will help to decrease the chances of infection and complications accompanying it.

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) She can walk without experiencing dizziness. b) Her blood pressure is below 140/90. c) Her urine output is over 50 mL/h. d) Her hematocrit level is over 45%.

b)Her blood pressure is below 140/90. Explanation: Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

The nurse is teaching a group of students about factors that place a pregnant woman at risk for infection in the postpartum period. Which of the following would the nurse be least likely to include? a) Loss of protection with premature rupture of membranes b) Increased vaginal acidity leading to growth of bacteria c) Prolonged labor with multiple vaginal examinations to evaluate progress d) Retained placental fragments

b)Increased vaginal acidity leading to growth of bacteria Explanation: Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth.

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which of the following as a possible effect? a) Ineffectiveness of breast-feeding b) Interference with the maternal-newborn attachment process c) Delayed development of the newborn d) Alteration in normal maternal hormonal function

b)Interference with the maternal-newborn attachment process Explanation: The nurse would include information that maternal postpartum complications affect not only the health status of the woman, but also that of the newborn by potentially interfering with the maternal-newborn attachment process. Furthermore, they can disrupt the dynamics of the entire family, with health-related, fiscal, and emotional effects and costs. Maternal postpartum complications are not known to result in ineffective breast-feeding, delayed development of the newborn, or altered maternal hormonal function.

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection? a) Method of delivery b) Length of labor c) Size of the neonate d) Maternal Rh status

b)Length of labor Explanation: A prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal delivery, and Rh status of the client don't place the mother at increased risk

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a) Administering ergonovine (Ergotrate) b) Massaging the fundus firmly c) Notifying the primary health care provider d) Performing bimanual compressions

b)Massaging the fundus firmly Explanation: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin (Pitocin). Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding doesn't respond to massage and oxytocin. The primary health care provider should be notified if the client doesn't respond to fundal massage, but other measures can be taken in the meantime.

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to a) Assess her blood pressure. b) Palpate her fundus. c) Have her turn to her left side. d) Assess her perineum.

b)Palpate her fundus. Explanation: Palpating the fundus will cause it to contract and reduce bleeding. This makes options A, C, and D incorrect.

Samantha delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment her contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating her fundus, you find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated; what should you do first? a) Ensure that her bladder is empty. b) Place one hand over the symphysis pubis. c) Insert uterine packing to control the hemorrhage. d) Seek an order to obtain and administer an oxytocic.

b)Place one hand over the symphysis pubis. Explanation: A boggy fundus with active bleedings and clots the day after delivery is indicative of uterus atony. The nurse should prepare to initiate fundal massage.The first step in this procedure is to place one had over the symphysis pubis. The first step in fundal massage is not to ensure that the patient's bladder is empty, seek an order for an oxytocic, nor insert uterine packing.

Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which of the following adverse effects? a) Headache b) Seizures c) Uterine hyperstimulation d) Flushing

b)Seizures Explanation: Seizures, hypertension, uterine cramping, nausea, vomiting, and palpitations are adverse effects of methylergonovine. Uterine hyperstimulation is an adverse effect of oxytocin. Flushing and headache are adverse effects of carboprost.

Which situation should concern the nurse treating a postpartum client within a few days of delivery? a) The client would like to watch the nurse give the baby her first bath b) The client feels empty since she delivered the neonate c) The client would like the nurse to take her baby to the nursery so she can sleep d) The client is nervous about taking the baby home

b)The client feels empty since she delivered the neonate Explanation: A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and wouldn't be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a) Moderate amount of lochia rubra b) Uterine atony c) Thrombophlebitis d) Hemoglobin level of 12 g/dl

b)Uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

A Hispanic woman who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which of the following causes of the hemorrhage is most likely in this client? a) Cervical laceration b) Uterine atony c) Retained placental fragment d) Disseminated intravascular coagulation

b)Uterine atony Explanation: Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario.

Which of the following is the most frequent reason for postpartum hemorrhage? a) Endometritis. b) Uterine atony. c) Perineal lacerations. d) Disseminated intravascular coagulation.

b)Uterine atony. Explanation: When a uterus does not contract well, the denuded placental surface can bleed excessively. Therefore options A, C, and D are incorrect.

Which complication is most likely responsible for a late postpartum hemorrhage? a) Cervical laceration b) Uterine subinvolution c) Perineal laceration d) Clotting deficiency

b)Uterine subinvolution Explanation: Late postpartum bleeding is usually the result of subinvolution of the uterus. Retained products of conception or infection commonly cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may have an immediate postpartum hemorrhage if the deficiency isn't corrected at the time of delivery.

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? a) Decreased respiratory rate b) Warm and flushed skin c) Elevated blood pressure d) Weak and rapid pulse

b)Weak and rapid pulse Explanation: The sign of weak and rapid pulse is the body in compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible. The other options are incorrect.

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her? a) Proper perineal care b) Wound care and hand washing c) Use of warm compresses and sitz baths d) Strict adherence to antibiotic therapy

b)Wound care and hand washing Explanation: The use of systemic corticosteroids prior to delivery has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand-washing.

Which of the following would lead the nurse to suspect that a postpartum woman has developed metritis? Select all that apply. a) Hematuria b) Leukocytosis c) Foul-smelling lochia d) Pain on both sides of the abdomen e) Flank pain

b)• Leukocytosis c)• Foul-smelling lochia d)• Pain on both sides of the abdomen Explanation: Signs and symptoms of metritis include lower abdominal tenderness or pain on one or both sides, foul-smelling lochia, and leukocytosis. Hematuria and flank pain would be associated with a urinary tract infection.

A patient is 32 weeks gestation and sent home on modified bedrest for preterm labor. She is on tocolyitics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse? a) "You will not be able to have intercourse again until 6 weeks after you deliver." b) "The need to keep the infant safe should be of more concern than when to have sex." c) "That is a question to ask your health care provider, at this point you are on pelvic rest to try and stop any further labor." d) "Intercourse has nothing to do with preterm labor; you can have sex with your husband."

c) "That is a question to ask your health care provider, at this point you are on pelvic rest to try and stop any further labor." Rationale: The patient needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider gives the OK. Option A is incorrect as it may be giving misinformation to the patient. Option B does not answer the patient's question so it is incorrect. Option D also gives misinformation to the patient and is incorrect.

A woman is going to have labor induced with oxytocin. Which statement below reflects the induction technique you anticipate her primary-care provider will order? a) Administer Pitocin in a 20 cc bolus of saline. b) Administer Pitocin in two divided intramuscular sites. c) Administer oxytocin diluted as a "piggyback" infusion. d) Administer oxytocin diluted in the main intravenous fluid.

c) Administer oxytocin diluted as a "piggyback" infusion. Rationale: Pitocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

Immediately after delivering a full-term infant, a patient develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this patient? a) Aspiration b) Placental separation c) Amniotic fluid embolism d) Congestive heart failure

c) Amniotic fluid embolism Rationale: With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.

After teaching a class about various methods for cervical ripening, the instructor determines that the teaching was successful when the class identifies which of the following as a surgical method? a) Laminaria b) Prostaglandin c) Amniotomy d) Breast stimulation

c) Amniotomy Rationale: Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which of the following would the nurse do to ensure a positive outcome for the client? a) Turn down oxytocin administration by half b) Administer hydration and sedation frequently c) Assess contractions by using external monitor d) Start administering tocolytic therapy

c) Assess contractions by using external monitor Rationale: In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs, not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently, and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

A client's membranes have just ruptured. Her fetus is presenting breech. Which of the following should the nurse do immediately to rule out prolapse of the umbilical cord in this client? a) Administer oxygen at 10 L/min by face mask b) Administer amnioinfusion c) Assess fetal heart sounds d) Place the woman in Trendelenburg position

c) Assess fetal heart sounds Rationale: To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

When educating the post-term pregnant patient, what should the nurse be sure to include to prevent fetal complications? a) Increase fluid intake to prevent dehydration. b) Be sure to measure 24-hour urine output daily. c) Be sure to monitor fetal movements daily. d) Monitor bowel movements.

c) Be sure to monitor fetal movements daily. Rationale: The nurse should be sure to teach the post-term patient to monitor fetal movements daily.

A woman at 32 weeks' gestation is admitted in preterm labor. On your admission assessment, which of following findings should cause the nurse to question the administration of a tocolytic agent? a) Strong, regular contractions. b) A spontaneous abortion in an earlier pregnancy. c) Cervical dilation of 5 cm. d) Fetus in a breech presentation.

c) Cervical dilation of 5 cm. Rationale: If cervical dilation has already progressed too far, labor cannot be halted. Tocolytics are usually not begun if cervical dilatation is over 3 to 4 cm. A breech presentation of the fetus is not cause to question the administration of a tocolytic agent, nor is it a spontaneous abortion in an earlier pregnancy.

A woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is post-term and has oligohydramnios. What does this increase the risk of during delivery? a) Shoulder dystocia b) Macrosomia c) Cord compression d) Fetal hydrocephalus

c) Cord compression Rationale: Oligohydramnios and meconium staining of the amniotic fluid are common complications of post-term pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

A woman's nurse-midwife tells her that the woman has developed dystocia. You would explain that this term means a) Muscle weakness related to prolonged labor. b) High blood pressure related to difficult labor. c) Difficult or abnormal labor. d) Potential for placental detachment.

c) Difficult or abnormal labor. Rationale: Dystocia is a general term used to describe difficult or abnormal labor. Dystocia does not indicate high blood pressure related to difficult labor, a potential for placental detachment, nor muscle weakness related to prolonged labor.

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? a) Forceps birth b) Trial labor c) External cephalic version d) Vacuum extraction

c) External cephalic version Rationale: External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but would be less likely to be used with a fetus in breech position.

A client in labor has been diagnosed with shoulder dystocia. Which of the following risk factors would the nurse expect to assess in the client? Select all that apply. a) Incompetent cervix b) Intrauterine growth restriction c) Fetal macrosomia d) Post-term pregnancy e) Maternal diabetes

c) Fetal macrosomia d) Post-term pregnancy e) Maternal diabetes Rationale: Risk factors of shoulder dystocia include maternal diabetes, maternal obesity, post-term pregnancy, fetal macrosomia, previous history of shoulder dystocia, and multiparity. Intrauterine growth restriction and incompetent cervix are not the risks associated with shoulder dystocia. Intrauterine growth restriction is one of the factors that increase the risk of a breech presentation. Incompetent cervix is a risk factor related to preterm labor.

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what do you prepare her? a) Careful monitoring of fetal kick counts b) Bed rest and hydration at home c) Hospitalization, tocolytic therapy, and IM corticosteroids d) An emergency cesarean section

c) Hospitalization, tocolytic therapy, and IM corticosteroids Rationale: At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the patient in the hospital allow for monitoring and a safe place if the woman continues and delivers. Administration of corticosteroids may help to develop the lungs and prepare for early preterm delivery. Sending the woman home is contraindicated in the scenario described. An emergency cesarean section is not indicated at this time. Monitoring fetal kick counts is typically done with a post-term pregnancy.

You are assisting with delivery of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to deliver but instead of continuing to emerge, it retracts into the vagina. What should you try first? a) Attempt to push one of the fetus' shoulders in a clockwise or counterclockwise motion. b) Zavanelli's maneuver c) McRobert's maneuver d) Apply pressure to the fundus.

c) McRobert's maneuver Rationale: This intervention is used with a large baby who may have shoulder dystocia and require assistance. The legs are sharply flexed, by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean delivery. Fundal pressure is contraindicated with shoulder dystocia. It is out of the province of the LVN to attempt delivery of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

Which action by the nurse would be least effective in assisting a couple who have experienced intrauterine fetal demise? a) Give the parents a lock of the infant's hair b) Assist the family in making arrangements for their stillborn infant c) Refrain from discussing the situation with the couple d) Allow the couple to spend as much time as they want with their stillborn infant.

c) Refrain from discussing the situation with the couple Rationale: The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

A multigravida presents at 31 weeks' gestation with signs and symptoms of preterm labor. The diagnosis is confirmed and she is admitted and given magnesium sulfate. What must you report as part of her care? a) Severe lower back pain, leg cramps, sweating b) Pain in the abdomen, shoulder, or back c) Respiratory depression, hypotension, absent tendon reflexes d) Low potassium or elevated glucose, tachycardia, chest pain

c) Respiratory depression, hypotension, absent tendon reflexes Rationale: Magnesium sulfate is a smooth muscle relaxant and can cause vaso-dilation and results in respiratory depression and severe hypotension at toxic levels. Options A, C, and D are incorrect indications of magnesium sulfate toxicity.

While in labor a woman with a prior history of cesarean birth complains of light-headedness and dizziness. The nurse assesses the patient and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms? a) Placentea previa b) Hypertonic uterus c) Uterine rupture d) Umbilical cord compression

c) Uterine rupture Rationale: The patient with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage and in this patient a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, nor umbilical cord compression.

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum? a) fraternal b) both types can result from the split ovum c) identical d) neither type results from a split ovum

c) identical Rationale: The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a)"Postpartum psychosis usually appears soon after the woman comes home." b)"Postpartum psychosis usually involves psychotropic drugs but not hospitalization." c)"Postpartum depression develops gradually, appearing within the first 6 weeks." d)"Postpartum blues usually resolves by the fourth or fifth postpartum day."

c)"Postpartum depression develops gradually, appearing within the first 6 weeks." Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the fourth to fifth postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

In which time period would the nurse most likely expect a client who has delivered twins to experience late postpartum hemorrhage? a) 24 to 48 hours after delivery b) 6 weeks to 3 months after delivery c) 24 hours to 6 weeks after delivery d) 6 weeks to 6 months after delivery

c)24 hours to 6 weeks after delivery Explanation: Late or secondary postpartum hemorrhages occur more than 24 hours but less than 6 weeks postpartum. Early or primary postpartum hemorrhages occur within 24 hours of delivery.

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection? a) Labor more than 12 hours long. b) Labor less than 12 hours long. c) A nonelective cesarean birth. d) A planned cesarean birth.

c)A nonelective cesarean birth. Explanation: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity.

The nurse is caring for a patient within the first four hours of her cesarean birth. Which of the following nursing interventions would be appropriate to prevent thrombophlebitis? a) Roll a bath blanket or towel and place it firmly behind the knees b) Assist client in performing leg exercises every two hours c) Ambulate the client as soon as her vital signs are stable d) Limit oral intake of fluids for the first 24 hours to prevent nausea

c)Ambulate the client as soon as her vital signs are stable Explanation: The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery. Options A, B, and C are incorrect.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching? a) Shortness of breath is a common adverse effect of the medication b) Wear knee-high stockings when possible c) Avoid over-the-counter (OTC) salicylates d) Avoid iron replacement therapy

c)Avoid over-the-counter (OTC) salicylates Explanation: Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron won't affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy? a) Sit with legs crossed over each other b) Refrain from performing any leg exercises c) Avoid products containing aspirin d) Avoid prolonged straining during defecation

c)Avoid products containing aspirin Explanation: The nurse should caution the client to avoid products containing aspirin, which inhibits the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. The nurse should not instruct the client to refrain from performing any leg exercises; instead the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises when caring for a client with cystocele and rectocele.

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates? a) Height, level of orientation, support systems b) Attachment, lochia color, complete blood cell count c) Blood pressure, pulse, complaints of dizziness d) Degree of responsiveness, respiratory rate, fundus location

c)Blood pressure, pulse, complaints of dizziness Explanation: Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? a) Offer analgesics prescribed by primary care provider b) Perform vigorous fundal massage for the client c) Check for bladder distention, while encouraging the client to void d) Use semi-Fowler's position to encourage uterine drainage

c)Check for bladder distention, while encouraging the client to void Explanation: If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? a)250mL b)300mL c)100mL d)500mL

d)500mL Explanation: Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Postpartum blues b) Maladjustment c) Postpartum psychosis d) Postpartum depression

c)Postpartum psychosis Explanation: Postpartum psychosis can present with a patient in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women. Maladjustment is a distracter for this question.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions? a) Postpartum panic disorder b) Postpartum depression c) Postpartum psychosis d) Postpartum blues

c)Postpartum psychosis Explanation: The client's signs and symptoms suggest that the the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily--often for no reason, and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristics of postpartum blues.

When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis? a) Tearful during appointment b) Talkative and asking questions c) Restless and agitated, concerned with self d) States being tired and happy at same time

c)Restless and agitated, concerned with self Explanation: When a woman has postpartum psychosis the signs may vary but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation. Therefore options A, B, and D are incorrect.

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response? a) Risk factors include frequent feeding. b) Risk factors include complete emptying of the breast c) Risk factors include nipple piercing. d) Risk factors include breast pumps.

c)Risk factors include nipple piercing. Explanation: Certain risk factors contribute to the development of mastitis. These include: inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; use of plastic-backed breast pads.

Every postpartum client has the potential of hemorrhage. While assessing a client's status, the nurse recognizes which of the following would not be used as an indicator of possible hemorrhage? a)Estimated amount of blood loss b)Uterine tone c)Signs of shock d)Vital signs

c)Signs of shock Explanation: Signs of shock do not appear until the hemorrhage is far advanced due to the increased fluid and blood volume of pregnancy. Vital signs would show an increased pulse rate and decreased level of consciousness. The amount of lochia would be much greater than usual and urinary output would be diminished, with signs of acute renal failure. The uterus may also appear soft and spongy, instead of firm.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? a) Group beta-hemolytic streptococci (GBS) b) Streptococcus pyogenes c) Staphylococcus aureus d) Escherichia coli

c)Staphylococcus aureus Explanation: The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis isn't harmful to the neonate. E. coli, GBS, and S. pyogenes aren't associated with mastitis. GBS infection is associated with neonatal sepsis and death.

The nurse recognizes that any client may develop postpartum hemorrhage and frequent assessments are conducted to ensure this is not happening. Which of the following is the most common cause of postpartum hemorrhage? a)Distended bladder b)Uterine lacerations c)Uterine Atony d)Placenta Previa

c)Uterine atony Explanation: The most common cause of postpartum hemorrhage is uterine atony, or failure of the uterus to contract and retract after birth. Any factor that causes the uterus to relax after birth will cause bleeding, even a full bladder that displaces the uterus. Placenta previa and uterine lacerations are potential contributors to hemorrhaging but not the main cause.

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which of the following complications? a)Postpartum Hemorrhage b)Uterine Atony c)Deep venous thrombosis d)Metritis

c)deep venous thrombosis Explanation: Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity.

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which of the following conditions in this client? a) Hypertonic contractions b) Braxton Hicks contractions c) Uncoordinated contractions d) Hypotonic contractions

d) Hypotonic contractions Rationale: With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be delivered. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia? a) McGeorge maneuver b) McDonald maneuver c) McRonald Maneuver d) McRoberts maneuver

d) McRoberts maneuver Rationale: McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for which of the following? a) Increased risk for cord entanglement b) Increased risk for uterine rupture c) Damage to the maternal tissues d) Potential lacerations and bleeding

d) Potential lacerations and bleeding Rationale: Forcible rotation of the forceps can cause potential lacerations and bleeding.. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released.

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. You are alone with her and notice that the umbilical cord is hanging out of the vagina. What should you do next? a) Prep the woman for a vaginal delivery. b) Go find assistance to confirm that the cord is in the vagina. c) With the woman in lithotomy position, hold her legs and sharply flex them toward her shoulders. d) Put her in bed immediately, call for help, and hold the presenting part of the cord.

d) Put her in bed immediately, call for help, and hold the presenting part of the cord. Rationale: Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, when the presenting part compresses the cord oxygen and nutrients are cut off to the baby and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident you do not put the woman in lithotomy position, and you do not leave the woman. A vaginal delivery is contraindicated in this situation.

Mrs. M. has been admitted to the delivery suite in labor. She has been in labor for 12 hours and is dilated to 4 cm. The physician notes that Mrs. M. is in hypotonic labor. What does this mean? a) The uterine contractions may or may not be regular, but the quantity or quality or strength is sufficient to dilate the cervix. b) The uterine contractions are irregular, but the quantity or quality or strength is insufficient to dilate the cervix. c) The uterine contractions are regular, but the quantity or quality or strength is insufficient to dilate the cervix. d) The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix.

d) The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix. Rationale: There are two types of uterine dysfunction: hypotonic and hypertonic. The most common is hypotonic dysfunction. This labor pattern manifests by uterine contractions that may or may not be regular, but the quantity or strength is insufficient to dilate the cervix.

A nurse is assessing a full-term patient in labor and determines the fetus is occiput posterior. The patient states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort? a) Have the physician administer a pudendal block. b) Place the patient supine with the head of bed elevated 30 degrees. c) Apply a warm washcloth to the lower back. d) Use a fist to apply counter pressure to the lower back.

d) Use a fist to apply counter pressure to the lower back. Rationale: Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.

The nursing student doing a clinical rotation in labor and delivery has noticed numerous women expressing various emotions during labor. The student's preceptor informs the student that these emotions can lead to psychological stress, which in turn can cause which of the following complications? a) deep vein thrombosis b) pulmonary emboli c) premature labor d) dystocia

d) dystocia Rationale: Many women experience an array of emotions during labor, which may include fear, anxiety, helplessness, desire to be alone, and weariness. These emotions can lead to psychological stress, which indirectly can cause dystocia.

A gravida 7, para 6 woman is in the hospital only 15 minutes when she begins to deliver precipitously. The fetal head begins to deliver as you walk into the labor room. Your best action would be to a) attach a fetal monitor to determine fetal status. b) ask her to push with the next contraction so delivery is rapid. c) assess blood pressure and pulse to detect placental bleeding. d) place a hand gently on the fetal head to guide delivery.

d) place a hand gently on the fetal head to guide delivery. Rationale: If a head is controlled as it delivers, trauma to internal vessels or to the maternal cervix is less apt to occur.

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which of the following conditions would the nurse identify as necessitating the cautious administration of this drug? a) Respiratory problems b) Low blood pressure c) Mild fever d) Cardiovascular disease

d)Cardiovascular disease Explanation: The nurse should know that the client with cardiovascular disease must understand that the drug has to be administered cautiously. Nurses must administer methylergonovine maleate with caution in women who have elevated blood pressure or cardiovascular disease because it causes a sudden increase in blood pressure and could initiate a cerebrovascular accident in women at risk with pre-existing conditions. Low blood pressure, respiratory problems, or mild fever is not known to enforce cautious use of methylergonovine maleate in clients with early postpartum hemorrhage.

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which of the following would be important to collect first? a)Urinalysis b)HIV status c)STI status d)Coagulation studies

d)Coagulation studies Explanation: Coagulation studies should be ordered immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status, although important, are not necessary emergently.

One of the primary assessments you, as a postpartum nurse, make every day is for postpartum hemorrhage. What do you assess the fundus for? a) Consistency, location, and place b) Content, lochia, place c) Location, shape, and content d) Consistency, shape, and location

d)Consistency, shape, and location Explanation: Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm. each postpartum day.

Within 24 hours of delivery, Diane begins to complain of pain in the pelvic region. Comfort measures and medication fail to eliminate the pain, her pulse is rapid, and her blood pressure, hematocrit, and hemoglobin are low. Her fundus is firm, however, and her lochia is dark red and flowing in only moderate amounts; no pooling is evident. You suspect a) Deep-vein thrombosis b) Retained placental fragments c) Lacerations in the uterus d) Deep pelvic hematoma

d)Deep pelvic hematoma Explanation: The assessment data indicate a blood loss in the body, and the lack of active bleeding leads one to believe it may be a hematoma. Retained placental fragments are characterized by late postpartum bleeding. Along with an abrupt onset of bleeding, the woman's uterus is not well-contracted. The woman with DVT may have no symptoms. If she does exhibit signs, these typically include swelling and calf pain or tenderness in the affected leg. The area may be warm, tender, and red. Homans' sign (pain on dorsiflexion of the foot) may be positive. Lacerations can occur as small tears or cuts in the perineal tissue, vaginal sidewall, or cervix.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect? a) Uterine inversion b) Uterine atony c) Hematoma d) Laceration

d)Laceration Explanation: Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright-red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis? a) Avoid massaging the breast area b) Apply cold compresses to the breast c) Avoid frequent breastfeeding d) Perform handwashing before breastfeeding

d)Perform handwashing before breastfeeding Explanation: As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold, not warm, moist heat to the breast. Gently massaging the affected area of the breast also helps.

Your patient is showing signs and symptoms of a pulmonary embolism. What should you do? a) Lay the patient flat and start oxygen. b) Sit the patient up 90 degrees and call the RN. c) Start oxygen at 2 to 3 liters per minute via nasal cannula. d) Raise the head of the bed to at least 45 degrees.

d)Raise the head of the bed to at least 45 degrees. Explanation: Immediate action is crucial for the woman who develops a pulmonary embolism. Immediately raise the head of the bed to at least 45 degrees to facilitate breathing. Begin oxygen therapy at 8 to 10 liters per minute via facemask and notify the physician.

When planning care for a postpartum patient, the nurse is aware the most common site for postpartum infection is which of the following? a) Urinary b) Breast c) Integumentary d) Reproductive

d)Reproductive Explanation: The most common site for a postpartum infection is the reproductive tract. This is important for teaching and education of the patients.

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis? a) Trendelenburg. b) On her left side. c) Flat in bed. d) Semi-Fowler's.

d)Semi-Fowler's. Explanation: A semi-Fowler's position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side or in the Trendelenburg position would be contraindicated.

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which of the following should alert the nurse to a potential infection in the client? a)Temperature of 37.5% C or higher after the first 12 hours after childbirth b)Temperature of 39% C or higher after the first 48 hours after childbirth c)Temperature of 38.5% C or higher after the first 36 hours after childbirth d)Temperature of 38% C or higher after the first 24 hours after childbirth

d)Temperature of 38% C or higher after the first 24 hours after childbirth Explanation: Postpartum infection is defined as a fever of 38% C or 100.4% F or higher after the first 24 hours after childbirth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours.

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply.

encouraging kangaroo care during procedures removing tape gently from the skin using a colorful mobile for distraction Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. Distraction using colorful mobiles or objects also can be effective. p 855

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

encouraging the client to wear a supportive bra. These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101° F (38.3° C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?

endometritis The woman with endometritis typically looks ill and commonly develops a fever of 100.4° F (38° C) or higher (more commonly 101° F [38.4° C], possibly as high as 104° F [40° C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absent

The nurse realizes that accommodating for the various cultural differences in her clients is an important aspect in providing their care. When caring for a Japanese-American postpartum woman, which action would be a priority?

ensuring that the newborn receives a daily bath In the Japanese-America culture, cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply.

epidurals excessive analgesia multiple gestation maternal exhaustion high fetal station at complete cervical dilation shoulder dystocia Early identification and prompt interventions for dystocia are essential to minimize risk to the woman and fetus. Factors associated with increased risk for dystocia include epidurals, excessive analgesia, multiple gestations, maternal exhaustion, ineffetive pushing technique, longer first stage of labor, fetal birth weight, maternal age of >35, ineffective uterine contractions, and high fetal station at complete cervical dilation.

A new mother asks the nurse why her baby's back and groin have a red and raised rash. The nurses uses which term to correctly identify this condition?

erythema toxicum

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external version External version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.) a) Perform fundal massage b) Administer methotrexate c) Estimate the size of the hematoma and report it d) Apply an ice pack to the site e) Administer an antibiotic f) Administer a mild analgesic as prescribed

f)• Administer a mild analgesic as prescribed d)• Apply an ice pack to the site c)• Estimate the size of the hematoma and report it Explanation: Report the presence of a perineal hematoma, its estimated size, and the degree of the woman's discomfort to her primary care provider. Administer a mild analgesic as prescribed for pain relief. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Usually a hematoma is absorbed over the next 3 or 4 days. An antibiotic is not required, as there is no indication of infection. Fundal massage is indicated for uterine atony, and methotrexate is used to destroy retained placental fragments when removal is not possible.

About 10 days following birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition?

femoral thrombophlebitis A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard, inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge.

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?

fever more than 100.4° F (38° C) 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.

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels

When caring for postpartum clients, the nurse would expect the birth attendant to prescribe what laboratory study the morning after the birth of the baby?

hemoglobin and hematocrit H&H Monitor the H&H and note the H&H before birth. Most practitioners prescribe a postpartum H&H on the morning after birth. If the values drop significantly, the woman may have experienced postpartum hemorrhage. Note the blood type and Rh. If the woman is Rh-, she will need a Rho(D) immune globulin workup. Determine the woman's rubella status. If she is nonimmune, she will need a rubella immunization before she is discharged home.

The nurse is assessing a neonate as he transitions to extrauterine life. The nurse integrates understanding that which structure closes as a result of tne neonate's first breath?

foramen ovale Before birth, the foramen ovale allowed most of the oxygenated blood entering the right atrium from the inferior vena cava to pass into the left atrium of the heart. With the newborn's first breath, air pushes into the lungs, triggering an increase in pulmonary blood flow and pulmonary venous return to the left side of the heart. As a result, the pressure in the left atrium becomes higher than in the right atrium. The increased left atrial pressure causes the foramen ovale to close, thus allowing the output from the right ventricle to flow entirely to the lungs. The closure of the ductus arteriosus depends on the high oxygen concentration of the aortic blood that results from aeration of the lungs at birth. Closure of the ductus venosus occurs because shunting from the left umbilical vein to the inferior vena cava is no longer needed. The umbilical arteries and vein begin to constrict at birth because with placental expulsion blood flow ceases.

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity?

fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate. pg 842

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?

generally within 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply.

gestational hypertension maternal infection congenital heart disease Prenatal risk factors that can help identify the newborn that may need resuscitation include history of substance abuse, gestational hypertension, fetal distress due to hypoxia before birth, chronic maternal diseases, maternal or perinatal infection, placental problems, umbilical cord problems, difficult or traumatic birth, multiple births, congenital heart disease, maternal anesthesia or recent analgesia, or preterm or postterm birth.

A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth?

glucose Glucose is the main source of energy for the first several hours after birth. With the newborn's increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours. Stored protein, brown fat, or carbohydrate are not associated with energy production in the newborn.

A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading the client's previous history based on which finding?

has previous lower abdominal incision The choice of a vaginal or repeat cesarean birth can be offered to women who had a lower abdominal incision. Contraindications to BVAC include a prior classic uterine incision, prior transfundal uterine surgery, uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff of facility if an emergency cesarean birth is required.

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common?

hearing

What are the functions of kangaroo care? Select all that apply.

helps the parents bond with their neonate keeps the neonate warm is skin-to-skin contact The method of keeping the neonate warm, kangaroo care, is an excellent way to meet the needs of the neonate and provide family-centered care. Kangaroo care does not cause hypothermia; it actually normalizes the neonate's temperature.

A nurse is reviewing the laboratory test results of a neonate. Which finding would be a cause of concern for the nurse? Select all that apply.

hematocrit 34% red blood cells 3.2 (1,000,000/uL) The neonate's hematocrit, which is below the normal value of 46% to 68%, and red blood cell count, which is below the normal range of 4.5 to 7.0 (1,000,000/uL) are a cause for concern. The hemoglobin, platelets, and white blood cells are within normal ranges for a neonate.

A small-for-gestational age neonate is admitted to the observational nursery for blood work. Which result would require further assessment?

hematocrit: 80%

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what does the nurse prepare her?

hospitalization, tocolytic therapy, and IM corticosteroids At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring and a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a postterm pregnancy.

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?

hypotonic contractions With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

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?

hypovolemia 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 premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.

increased serum bilirubin levels clay-colored stools tea-colored urine Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants in this scenario. Mongolian spots are not associated with newborn jaundice.

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor?

increased vaginal acidity leading to growth of bacteria Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth.

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:

increasing birth weight. Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in up to 2% of vaginal births. pg 758

A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2° F; (38.4° C) HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?

infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection.

A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: temp 101.2° F (38.4° C); HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?

infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

The nurse is aware that the infant's circulatory dynamics during transition can be greatly affected by which action?

late clamping of the umbilical cord after 3 minutes Early (before 30 to 40 seconds) or late (after 3 minutes) clamping of the umbilical cord changes circulatory dynamics during transition. Recent studies indicate that the benefits of delayed cord clamping include improving the newborn's cardiopulmonary adaptation, preventing iron-deficient anemia in full-term newborns without increasing hypervolemia-related risks and increased iron stores, increasing blood pressure, improving oxygen transport, and increasing red blood cell flow (McAdams, 2014). Although a tailored approach is required in the case of cord clamping, current available data suggests that delayed cord clamping offers the newborn many benefits physiologically which include at least a 30 percent increase in blood volume for term infants and a 50 percent increase in preterm infants; improvement of systemic blood pressure; increase in the cerebral oxygen index; higher hemoglobin levels at 24 to 48 hours of age and increased serum iron levels at 4 to 6 months.

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:

maintain previous household routines to prevent infection. The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply.

maternal smoking during pregnancy asthma exacerbations during pregnancy drug abuse

A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?

newly born preterm infant Newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. The preterm newborn has an inadequate supply of brown fat. The preterm newborn also has decreased muscle tone and thus cannot assume the flexed fetal position, which reduces the amount of skin exposed to a cooler environment. Preterm newborns have large body surface areas compared to their weight. A term infant with RH factor will not be at any greater risk for heat lost and stabilized with age. A 2-day-old infant postmaturity would not be stabilized and would initially be at risk for heat loss. The diabetic infant is stabilized and heat loss is not a great concern. pg 850

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia. pg 858

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanug; and meconium-stained skin and fingernails. pg 840

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching? moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.

Which lochia pattern should be reported immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the healthcare provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding; as is lochia progressing from rubra to serosa to alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5.

After a gavage feeding of a preterm neonate, the nurse aspirates 4 mL of undigested formula. This finding may indicate the development of which complication?

necrotizing enterocolitis

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior?

negative attachment Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors

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

A nurse is conducting a prenatal class for some clients who are in their third trimester with the topic being preventing misidentification. The nurse determines the session is successful after the participates correctly choose which items will be on matching identification bracelets?

newborn's sex and date and time of birth

A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?

newly born preterm infant

A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development?

paternal factors

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus

one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately?

oral temperature 100.8° F (38.2° C) A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A pulse rate of 75 beats/minute, respiratory rate of 16 breaths/minute, and a fundus 1 cm below the umbilicus are normal findings.

A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response?

orientation The neonate is demonstrating orientation, the neonate's ability to respond to auditory and visual stimuli, as demonstrated by the movement of head and eyes to focus on that stimuli. Habituation is the newborn's ability to process and respond to visual and auditory stimuli. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. 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. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves. pg 580

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 Expected newborn behaviors include orientation, habituation, motor maturity, self-quieting ability, and social behaviors. Any deviation in behavioral responses requires further assessment because it may indicate a complex neurobehavioral problem.

A nurse is preparing to place a skin temperature probe on a neonate who is lying on his back. To ensure an accurate reading, which location would be most appropriate to use for placement?

over the liver A skin temperature probe should not be placed over a bony area or one with brown fat (such as between the scapulae, at the nape of the neck or above the kidneys) because it does not give an accurate assessment of the whole body temperature. To ensure the best accuracy, most temperature probes are placed over the liver when the newborn is supine or side-lying

When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate?

over the liver To obtain accurate assessment of whole body temperature, a skin temperature probe should be placed over the liver if the newborn is supine or in the side-lying position. Bony areas such as the hip or areas with brown fat such the mediastinum or between the scapulae should be avoided because these areas do not give accurate readings.

Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which medication would the nurse administer as prescribed after repositioning?

oxytoxic agent The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.

When assessing a client for postpartum hemorrhage, the nurse monitors what every hour?

pad count The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding.

A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to:

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding.

Two weeks after their baby is born, a father calls to report that his wife is behaving strangely. She is extremely talkative and energetic, and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when the father asks her about the child, "As if," the father says, "she's forgotten that we even have a baby!" The nurse tells him to bring the mother in right away because the nurse suspects the mother is suffering from what condition?

postpartum psychosis Postpartum psychosis can present with a client in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis The client's signs and symptoms suggest that the the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason, and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristics of postpartum blues.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding. Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released. pg 790

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place (precipitous labor).

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?

preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from start of contraction to birth.

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 on the chest Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and fathers to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breast-feeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care.

When examining a newborn female, the nurse notices a small pinkish discharge from the vaginal area. What should the nurse suspect?

pseudomenstruation, a normal finding

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:

pulmonary embolism. These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

radiation, convection, and conduction Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production pg 570

The nurse is caring for a client of Asian descent 1 day after she has given birth. Which foods will the client most likely refuse to eat when her meal tray is delivered? Select all that apply.

raw carrots and celery ice cream orange slices Many people of Latin American, African, and Asian descent believe that good health involves a balance of heat and cold. The blood loss during birth is considered loss of warmth, leaving the woman in a cold state. Therefore, cold foods are avoided during this time. Hot soup and mashed potatoes with gravy would provide the warm foods that are desired.

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

reciprocity 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.

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? taking-hold letting-go acquaintance/attachment taking-in

taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase?

taking-in phase During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in?

taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the puerperium.

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea-colored urine Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia. pg 837

All of the following are ways the nurse can encourage bonding between the parents and the newborn except:

telling the mother that the best way to bond with her baby is to breastfeed.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temperature The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client?

temperature of 38° C or higher after the first 24 hours after birth Postpartum infection is defined as a fever of 38° C or 100.4° F or higher after the first 24 hours after birth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours.

The nurse determines a newborn is small-for-gestational age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores The nurse should perform a thorough physical examination of the newborn and closely observe the newborn for typical SGA characteristics, which include the following: a newborn head that is disproportionately large compared with rest of body; a wasted appearance of extremities with reduced subcutaneous fat stores; a reduced amount of breast tissue; poor muscle tone over buttocks and cheeks; and a thin umbilical cord pg 834

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

weak and rapid pulse The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible.

A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when?

within 3 months of giving birth Postpartum psychosis generally surfaces within 3 months of giving birth

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

women on antithyroid medications women on antineoplastic medications women using street drugs While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

A client who is hypertensive and who received corticosteroids during pregnancy gave birth by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care the nurse should teach her?

wound care and hand washing The use of systemic corticosteroids prior to birth has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand washing.

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days?

yellow-green, pasty, unpleasant-smelling stool The stool of formula-fed newborns varies depending on the type of formula ingested, but it typically is yellow, yellow-green, or greenish, loose, pasty, or formed with an unpleasant odor. Greenish-black tarry stool denotes meconium. Thin, yellowish, seedy brown stool characterizes the transitional stool that occurs after meconium. Sour-smelling yellowish-gold stool that is loose and stringy to pasty in consistency is typical of a breastfed newborn stool.