OB

A nurse has provided discharge instructions to a client who delivered a healthy infant by cesarean delivery. Which statement made by the client indicates a need for further instructions? 1. "I will begin abdominal exercises immediately." 2. "I will notify the physician if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than the newborn infant for at least 2 weeks."

1. "I will begin abdominal exercises immediately." A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. The instructor determines that the student needs to research this procedure further if the student states that: 1. "I will flush the eyes after instilling the ointment." 2. "I will clean the newborn's eyes before instilling ointment." 3. "I need to administer the eye ointment within 1 hour after delivery." 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs."

1. "I will flush the eyes after instilling the ointment." Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush would wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the newborn.

A postpartum nurse is providing instructions to a client after delivery of a healthy infant . The nurse instructs the client that she should expect normal bowel elimination to return: 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum

1. 3 days postpartum After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply? 1. 7 days after fertilization 2. 14 days after fertilization 3. 21 days after fertilization 4. 28 days after fertilization

1. 7 days after fertilization Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium. During the 2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the 3rd week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures — the primitive streak, notochord, and allantois — form. Early during the 4th week (28 days after implantation), cellular differentiation and organization occur.

The uterus returns to the pelvic cavity in which time frame? 1. 7th to 9th day postpartum 2. 2 weeks postpartum 3. End of the 6th week postpartum 4. When the lochia changes to alba

1. 7th to 9th day postpartum The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. This is known as subinvolution.

A clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at high risk for contracting human immunodeficiency virus (HIV)? 1. A client who has a history of intravenous drug use 2. A client who has a significant other who is heterosexual 3. A client who has a history of sexually transmitted diseases 4. A client who has had one sexual partner for the past 10 years

1. A client who has a history of intravenous drug use Human immunodeficiency virus (HIV) is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals with persistent and recurrent sexually transmitted infections, individuals who have a history of multiple sexual partners, and individuals who have used intravenous drugs. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.

Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes? 1. A neonate who's in good condition 2. A neonate who's mildly depressed 3. A neonate who's moderately depressed 4. A neonate who needs additional oxygen to improve the Apgar score

1. A neonate who's in good condition An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The physician prescribes a contraction stress test, and the results are documented as negative. A nurse interprets the finding of the contraction stress test as indicating: 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery

1. A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations.

Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? 1. An increased sense of rectal pressure 2. A decrease in intensity of contractions 3. An increase in fetal heart rate variability 4. Episodes of nausea and vomiting

1. An increased sense of rectal pressure An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur.

Late in the first stage of labor, a client receives a spinal block to relieve discomfort. A short time later, her husband tells the nurse that his wife feels dizzy and is complaining of numbness around her lips. What do the client's symptoms suggest? 1. Anesthesia overdose 2. Transition to the second stage of labor 3. Anxiety 4. Dehydration

1. Anesthesia overdose Dizziness, circumoral numbness, and slurred speech indicate anesthesia overdose. Transition to the second stage of labor is marked by an increased urge to push, an increase in bloody show, grunting, gaping of the anus, involuntary defecation, thrashing about, loss of control over breathing techniques, and nausea and vomiting. Anxiety and dehydration rarely cause dizziness or circumoral numbness.

The nurse is caring for a client during the 1st postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? 1. Apply an ice pack to her perineum. 2. Take a sitz bath. 3. Perform perineal care after voiding or a bowel movement. 4. Drink plenty of fluids.

1. Apply an ice pack to her perineum. A cold pack applied to an episiotomy during the first 24 hours after delivery may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may reduce discomfort by promoting circulation and healing. While perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection — not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve perineal discomfort.

A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which of the following would be the nurse's initial action? 1. Assess for presence of a full bladder. 2. Suggest the placement of an internal uterine pressure catheter to determine adequacy of contractions. 3. Encourage the mother to relax by assisting her with appropriate breathing techniques. 4. Suggest to the physician that oxytocin augmentation be started to stimulate labor.

1. Assess for presence of a full bladder. A full bladder will slow or stop cervical dilation and produce symptoms that could be misdiagnosed as arrest in labor. Other strategies, such as internal uterine monitoring, relaxation, and oxytocin augmentation, would be appropriate later, but assessing the bladder first is key.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin (Pitocin). When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? 1. Contractions will be stronger and more uncomfortable and will peak more abruptly. 2. Contractions will be weaker, longer, and more effective. 3. Contractions will be stronger, shorter, and less uncomfortable. 4. Contractions will be stronger and shorter and will peak more slowly.

1. Contractions will be stronger and more uncomfortable and will peak more abruptly. Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions. Oxytocin doesn't affect the duration of contractions.

During the postpartum period, the nurse should assess for signs of normal involution. Which statement would indicate that the client is progressing normally? 1. The uterus is descending at the rate of one fingerbreadth per day. 2. Blood pressure drops as a result of the birth and changed circulatory load. 3. Urine output remains about the same as in the client's prenatal period. 4. Pad usage remains at 10 to 15 per day.

1. The uterus is descending at the rate of one fingerbreadth per day. During the normal involutional process, the uterus will descend approximately one fingerbreadth per day. Blood pressure doesn't change during the postpartum period. Urine output typically increases after delivery. Usually, the client will need six to seven perineal pads per day at this time.

While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which situation? 1. This is a normal adverse effect of phototherapy. 2. The baby is developing lactose intolerance and needs a soy-based formula. 3. The bilirubin is rising to dangerous levels. 4. The neonate may have a malabsorption problem.

1. This is a normal adverse effect of phototherapy. Phototherapy increases gastric motility, causing the neonate to have many green, watery stools. The increased gastric motility also causes the neonate to be irritable. There is no evidence that the neonate has a lactose intolerance or malabsorption problem, nor is there evidence that the neonate's bilirubin levels are rising to dangerous levels.

The nurse is discussing posture with a client who's 18 weeks pregnant. Why should the nurse caution her to avoid the supine position? 1. This position impedes blood flow to the fetus. 2. This position may trigger heart palpitations. 3. This position may cause gastroesophageal reflux. 4. This position promotes pregnancy-induced hypertension (PIH).

1. This position impedes blood flow to the fetus. After the 4th month of pregnancy, the client should avoid the supine position because it allows the gravid uterus to compress veins, blocking blood flow to the fetus. No evidence suggests that the supine position triggers heart palpitations, causes esophageal reflux, or promotes PIH.

Which instruction should the nurse give to a client who's 26 weeks pregnant and complains of constipation? 1. Encourage her to increase her intake of roughage and to drink at least six glasses of water per day. 2. Tell her to ask her caregiver for a mild laxative. 3. Suggest the use of an over-the-counter stool softener. 4. Tell her to go to the evaluation unit because constipation may cause contractions.

1. Encourage her to increase her intake of roughage and to drink at least six glasses of water per day. The best instruction is to encourage the client to increase her intake of high-fiber foods (roughage) and to drink at least six glasses of water per day. Mild laxatives and stool softeners may be needed, but dietary changes should be tried first. Straining during defecation and diarrhea can stimulate uterine contractions, but telling the client to go to the evaluation unit doesn't address her concern.

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/ min. Which of the following nursing actions is appropriate? 1. Notify the physician or nurse-midwife. 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

1. Notify the physician or nurse-midwife. A normal fetal heart rate is 120 to 160 beats/ min, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

Initial client assessment information includes the following: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which of the following complaints? 1. Headache, blurred vision, and facial and extremity swelling 2. Abdominal pain, urinary frequency, and pedal edema 3. Diaphoresis, nystagmus, and dizziness 4. Lethargy, chest pain, and shortness of breath

1. Headache, blurred vision, and facial and extremity swelling The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most preeclamptic clients have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia.

The nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this time, the nurse expects to assess: 1. Hegar's sign. 2. fetal outline. 3. ballottement. 4. quickening.

1. Hegar's sign. When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign (softening of the uterine isthmus) between the 6th and 8th weeks of pregnancy. The fetal outline may be palpated after 24 weeks. Ballottement isn't elicited until the 4th or 5th month of pregnancy. Quickening typically is reported after 16 to 20 weeks.

A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of which of the following? 1. How well the neonate tolerated labor 2. How well the neonate has adapted to extrauterine life 3. How well the neonate stabilizes his temperature after birth 4. Gestational age of the neonate

1. How well the neonate tolerated labor Apgar scores, given at 1 and at 5 minutes after delivery, indicate how well the neonate tolerated labor and how well he made the transition to extrauterine life. These scores also provide the foundation for additional nursing interventions, if needed. Apgar scores aren't used to determine the gestational age of the neonate.

During the first 3 months, which of the following hormones is responsible for maintaining pregnancy? 1. Human chorionic gonadotropin (HCG) 2. Progesterone 3. Estrogen 4. Relaxin

1. Human chorionic gonadotropin (HCG) HCG is the hormone responsible for maintaining the pregnancy until the placenta is in place and functioning. Serial HCG levels are used to determine the status of the pregnancy in clients with complications. Progesterone and estrogen are important hormones responsible for many of the body's changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting her to seek rest.

A client calls to schedule a pregnancy test. The nurse knows that most pregnancy tests measure which hormone? 1. Human chorionic gonadotropin (hCG) 2. Human placental lactogen 3. Human chorionic thyrotropin 4. Estradiol

1. Human chorionic gonadotropin (hCG) Widely used pregnancy tests detect hCG in the blood and urine by immunologic tests specific for the beta subunit of hCG. Human placental lactogen, human chorionic thyrotropin, and estradiol are hormones produced by the placenta; however, they aren't used to detect pregnancy.

The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be prepared for which maternal adverse reactions? 1. Hypertension 2. Jaundice 3. Dehydration 4. Fluid overload 5. Uterine tetany 6. Bradycardia

1. Hypertension 4. Fluid overload 5. Uterine tetany Adverse reactions to oxytocin in the mother include hypertension, fluid overload, and uterine tetany. The antidiuretic effect of oxytocin increases renal reabsorption of water, leading to fluid overload — not dehydration. Jaundice and bradycardia are adverse reactions that may occur in the neonate. Tachycardia, not bradycardia, is reported as a maternal adverse reaction.

A client in labor receives epidural anesthesia. The nurse should assess carefully for which adverse reaction to the anesthetic agent? 1. Hypotensive crisis 2. Fetal tachycardia 3. Increased urine output 4. Increased beat-to-beat variability in the fetal heart rate (FHR)

1. Hypotensive crisis Hypotensive crisis may occur after epidural anesthesia administration as the anesthetic agent spreads through the spinal canal, blocking sympathetic innervation. Other signs and symptoms of hypotensive crisis associated with epidural anesthesia may include fetal bradycardia (not tachycardia) and decreased (not increased) beat-to-beat variability in the FHR. Urine retention, not increased urine output (polyuria), may occur during the postpartum period.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is appropriate? 1. Notify the physician. 2. Document the findings. 3. Reassess the client in 2 hours. 4. Encourage increased oral intake of fluids.

1. Notify the physician. Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of the blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the physician. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

A postpartum client visits her physician to discuss contraception. After a thorough discussion, the client decides to use oral contraceptives. The physician prescribes ethinyl estradiol-ethynodiol diacetate (Demulen 1/35-21), one tablet by mouth daily, followed by 7 days without a dose before beginning the next cycle of tablets. Which type of combination oral contraceptive is ethinyl estradiol-ethynodiol diacetate? 1. Monophasic 2. Biphasic 3. Triphasic 4. Progestin-dominant triphasic

1. Monophasic Ethinyl estradiol-ethynodiol diacetate is a monophasic oral contraceptive agent.

When magnesium sulfate is administered to a client in labor, its action occurs at which site? 1. Neural-muscular junctions 2. Distal renal tubules 3. Central nervous system (CNS) 4. Myocardial fibers

1. Neural-muscular junctions Because magnesium has chemical properties similar to those of calcium, it will assume the role of calcium at the neural muscular junction. It doesn't act on the distal renal tubules, CNS, or myocardial fibers.

When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to do which of the following? 1. Prevent seizures 2. Reduce blood pressure 3. Slow the process of labor 4. Increase diuresis

1. Prevent seizures The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.

A nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive and understands that this indicates: 1. Normal findings 2. Abnormal findings 3. The need for further evaluation 4. That the findings on the monitor were difficult to interpret

1. Normal findings A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within normal range (120 to 160 beats/ min) with good long-term variability. In addition, two or more fetal heart rate accelerations of at least 15 beats/ min must occur, each with a duration of at least 15 seconds, in a 20-minute interval.

A client takes an oral contraceptive to prevent pregnancy. The nurse should instruct her to use an alternative contraceptive method when receiving which drug concomitantly? 1. Primidone (Mysoline) 2. Cyclosporine (Sandimmune) 3. Erythromycin (Erythrocin) 4. Hydrocortisone (Cortef)

1. Primidone (Mysoline) Primidone, an anticonvulsant, may decrease the efficacy of oral contraceptives, necessitating use of an alternative contraceptive method. Concomitant use of oral contraceptives with cyclosporine increases the plasma concentration of cyclosporine. No interaction occurs between erythromycin and oral contraceptives. Oral contraceptives enhance the anti-inflammatory actions of hydrocortisone.

A home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Generalized edema 5. Increased pulse rate 6. Increased respiratory rate

1. Proteinuria 2. Hypertension 4. Generalized edema The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia.

A mother with a past history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data below would lead to this nursing judgment? 1. Sudden dyspnea 2. Chills, fever 3. Diaphoresis 4. Hypertension 5. Confusion

1. Sudden dyspnea 3. Diaphoresis 5. Confusion Sudden dyspnea with diaphoresis and confusion are classic signs and symptoms of dislodgment of a thrombus (stationary blood clot) from a varicose vein becoming an embolus (moving clot) that lodges itself into the pulmonary circulation. Chills and fever would indicate an infection. A client with an embolus could be hypotensive, not hypertensive.

A client is in the last trimester of pregnancy. The nurse should instruct her to notify her primary health care provider immediately if she notices: 1. blurred vision. 2. hemorrhoids. 3. increased vaginal mucus. 4. dyspnea on exertion.

1. blurred vision. Blurred vision or other visual disturbances, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for the client and fetus. Although hemorrhoids may be a problem during pregnancy, they don't require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses.

An expected fetal adverse reaction to meperidine (Demerol) during labor is: 1. decreased beat-to-beat variability. 2. bradycardia. 3. late decelerations. 4. none known.

1. decreased beat-to-beat variability. Possible fetal adverse reactions include both moderate central nervous system depression and decreased beat-to-beat variability. Bradycardia and late decelerations don't occur as a result of meperidine administration.

At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of pregnancy-induced hypertension (PIH). Based on this diagnosis, the nurse expects assessment to reveal: 1. edema. 2. fever. 3. glycosuria. 4. vomiting.

1. edema. Classic signs of PIH include edema (especially of the face), elevated blood pressure, and proteinuria. Fever is a sign of infection. Glycosuria indicates hyperglycemia. Vomiting may be associated with various disorders.

The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that: 1. the delivery may need to be induced early. 2. the delivery must be by cesarean. 3. the mother will carry to term safely. 4. it's too early to tell.

1. the delivery may need to be induced early. Early induction or early cesarean are possibilities if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary.

During a physical examination, a client who's 32 weeks pregnant becomes pale, dizzy, and light-headed while supine. Which action should the nurse immediately take? 1. Turn the client on her left side. 2. Ask the client to breathe deeply. 3. Listen to fetal heart tones. 4. Measure the client's blood pressure.

1. Turn the client on her left side. As the uterus enlarges, pressure on the inferior vena cava increases, compromising venous return and causing blood pressure to drop. This may lead to syncope and accompanying symptoms when the client is supine. Turning the client on her left side relieves pressure on the vena cava, restoring normal venous return and blood pressure. Deep breathing wouldn't relieve this client's symptoms. Listening to fetal heart tones and measuring the client's blood pressure wouldn't provide relevant information nor would they treat the client's symptoms.

Complications of gestational hypertension

1. Abruptio placentae 2. Disseminated intravascular coagulation 3. Thrombocytopenia 4. Placental insufficiency 5. Intrauterine growth restriction 6. Intrauterine fetal death

Presumptive signs of pregnancy

1. Amenorrhea 2. Nausea and vomiting 3. Increased size and increased feeling of fullness in breasts 4. Pronounced nipples 5. Urinary frequency 6. Quickening: The first perception of fetal movement by the mother may occur the sixteenth to twentieth week of gestation. 7. Fatigue 8. Discoloration of the vaginal mucosa

During her first prenatal visit, a client expresses concern about gaining weight. Which would be the nurse's best action? 1. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. 2. Be alert for a possible eating problem and do a further in-depth assessment. 3. Report the client's concerns to her caregiver. 4. Ask her to come back to the clinic every 2 weeks for a weight check.

1. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. Weight gain during pregnancy is a normal concern for most women. The nurse must first teach the client about normal weight gain and diet in pregnancy, then assess the client's response to that information. It's also important for the nurse to determine whether the client has any complicating problems such as an eating disorder. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. A weight check every 2 weeks also is unnecessary.

Pregnancy and the endocrine system

1. Basal metabolic rate increases and metabolic function increases. 2. The anterior lobe of the pituitary gland enlarges. 3. The thyroid enlarges slightly, and thyroid activity increases. 4. The parathyroid increases in size. 5. Aldosterone levels gradually increase. 6. Body weight increases. 7. Water retention is increased, which can contribute to weight gain.

Actions to Take for a Nonreassuring Fetal Heart Rate Pattern

1. Identify the cause. 2. Discontinue oxytocin (Pitocin) infusion. 3. Change the mother's position. 4. Administer oxygen by face mask at 8 to 10 L/ min and infuse intravenous fluids as prescribed. 5. Prepare to initiate continuous electronic fetal monitoring with internal devices if not contraindicated. 6. Prepare for cesarean delivery if necessary. 7. Document the event, actions taken, and the mother's response.

Pregnancy and the respiratory system

1. Oxygen consumption increases by approximately 15% to 20%. 2. Diaphragm is elevated because of the enlarged uterus. 3. Shortness of breath may be experienced.

Predisposing conditions for preeclampsie

1. Primigravida 2. Women younger than 19 years or older than 40 years 3. Chronic renal disease 4. Chronic hypertension 5. Diabetes mellitus 6. Rh incompatibility 7. History of or family history of gestational hypertension

Lochia normally progresses in which pattern? 1. Rubra, serosa, alba 2. Serosa, rubra, alba 3. Serosa, alba, rubra 4. Rubra, alba, serosa

1. Rubra, serosa, alba As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect.

A client recently delivered a baby boy. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin (Syntocinon) into each nostril. Why is the client using this drug? 1. To stimulate lactation 2. To treat eclampsia 3. To reduce postpartum bleeding 4. To treat erythroblastosis

1. To stimulate lactation Oxytocin is administered as a nasal spray before breast-feeding to stimulate lactation. When oxytocin is used to treat eclampsia, reduce postpartum bleeding, or treat erythroblastosis fetalis, the drug is administered parenterally.

Assessment findings for DIC

1. Uncontrolled bleeding 2. Bruising, purpura, petechiae, and ecchymosis 3. Presence of occult blood in excretions such as stool 4. Hematuria, hematemesis, or vaginal bleeding 5. Signs of shock 6. Decreased fibrinogen level, platelet count, and hematocrit level 7. Increased prothrombin time and partial thromboplastin time, clotting time, and fibrin degradation products

The nurse uses nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color? 1. Pink 2. Blue 3. Yellow 4. Green

2. Blue Nitrazine paper turns blue on contact with alkaline substances such as amniotic fluid. Normal vaginal discharge and urine are acidic and cause nitrazine paper to turn pink.

Which of the following should be the nurse's initial action immediately following the birth of the baby? 1. Aspirating mucus from the infant's nose and mouth 2. Drying the infant to stabilize the infant's temperature 3. Promoting parental bonding 4. Identifying the newborn

2. Drying the infant to stabilize the infant's temperature The nurse's first action is to dry the baby and stabilize the infant's temperature. Aspiration of the infant's nose and mouth occurs at the time of delivery. Promoting parental bonding and identifying the neonate are appropriate after the baby has been dried.

Which of the following correctly defines puerperium? 1. The 1st hour after birth 2. The 6 weeks following birth 3. The days spent in the hospital 4. The duration of breast-feeding

2. The 6 weeks following birth Puerperium is defined as the 6 weeks postpartum. The other options are incorrect.

A nurse is reviewing the record of a client in the labor room and notes that the nurse -midwife has documented that the fetus is at − 1 station. The nurse determines that the fetal presenting part is: 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spine 4. 1 fingerbreadth below the symphysis pubis

3. 1 cm above the ischial spine Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, measured in centimeters, and noted as a negative number above the line and a positive number below the line. At negative 1 (− 1) station, the fetal presenting part is 1 cm above the ischial spines.

A healthy term white male neonate should weigh approximately: 1. 7 lb (3.2 kg). 2. 8 lb (3.6 kg). 3. 7.7 lb (3.5 kg). 4. an amount that varies with length of pregnancy.

3. 7.7 lb (3.5 kg). The normal weight for a term white male neonate should be about 7.7 lb. White females should weigh about 7.5 lb. Neonates of Asian or black mothers often weigh less.

The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? 1. Presence of menses 2. Uterine enlargement 3. Breast sensitivity 4. Fetal heart tones

3. Breast sensitivity Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy.

What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum? 1. Puerperal infection 2. Mastitis 3. Dehydration 4. Chorioamnionitis

3. Dehydration A slight temperature elevation from dehydration is common during the first 24 hours after delivery. Infection should be suspected if the client's temperature exceeds 100.4° F (38° C) for 2 successive days after delivery, excluding the first 24 hours.

Which of the following would be an inappropriate indication of placental detachment? 1. An abrupt lengthening of the cord 2. An increase in the number of contractions 3. Relaxation of the uterus 4. Increased vaginal bleeding

3. Relaxation of the uterus Relaxation isn't an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus.

A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for: 1. irregular contractions. 2. increased fetal movement. 3. changes in cervical effacement and dilation after 1 to 2 hours. 4. contractions that feel like pressure in the abdomen and groin.

3. changes in cervical effacement and dilation after 1 to 2 hours. True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours, regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly, bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or dilation even after 1 or 2 hours.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what other intervention should be performed? 1. Slow the intravenous flow rate. 2. Place the client in a high Fowler's position. 3. Continue the oxytocin (Pitocin) drip if infusing. 4. Administer oxygen, 8 to 10 L/ min, via face mask.

4. Administer oxygen, 8 to 10 L/ min, via face mask. Oxygen is administered, 8 to 10 L/ min, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect because the intravenous infusion should be increased to increase the maternal blood volume. Option 2 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion. Option 3 is incorrect because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason.

After an amniotomy has been performed, a nurse should first assess: 1. For cervical dilation 2. For bladder distention 3. The maternal blood pressure 4. The fetal heart rate pattern

4. The fetal heart rate pattern True labor is present when contractions increase in duration and intensity . Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4. Variable decelerations Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement . Early decelerations result from pressure on the fetal head during a contraction.

The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to: 1. start using insulin. 2. start taking an oral antidiabetic drug. 3. monitor her urine for glucose. 4. be taught about diet.

4. be taught about diet. The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall diet intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels.

A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she: 1. express milk manually. 2. take antilactation drugs. 3. take hot showers. 4. wear a supportive, well-fitting brassiere.

4. wear a supportive, well-fitting brassiere. The proper brassiere helps prevent breast engorgement by providing support and acting as a barrier to breast stimulation. Antilactation drugs are no longer recommended because a rebound effect may occur after they're discontinued; also, they're expensive and may cause adverse effects. Manual milk expression and hot showers stimulate the breasts, triggering milk production and prolonging the discomfort of engorgement.

Women of what age are more at risk for adverse perinatal outcomes?

<20 >35

Insulin requirements after placental delivery

After placental delivery, placental hormone levels abruptly decrease and insulin requirements decrease.

Psychological changes in pregnancy

Ambivalence Acceptance Emotional lability Body image changes Relationship with the fetus

Nägele's rule

Determines the estimated date of birth based on the premise that the woman has a 28-day menstrual cycle. Add 7 days to the first day of the last menstrual period; subtract 3 months and add 1 year. Alternatively, add 7 days to the last menstrual period and count forward 9 months.

Maternal Cardiac Disease Risk Groups

Group I (Mortality Rate 1%) Corrected tetralogy of Fallot Pulmonic or tricuspid disease Mitral stenosis (classes I and II) Patent ductus arteriosus Ventricular septal defect Atrial septal defect Porcine valve Group II (Mortality Rate 5%-15%) Mitral stenosis with atrial fibrillation Artificial heart valves Mitral stenosis (classes III and IV) Uncorrected tetralogy Aortic coarctation (uncomplicated) Aortic stenosis Group III (Mortality Rate 25%-50%) Aortic coarctation (complicated) Myocardial infarction Marfan syndrome True cardiomyopathy Pulmonary hypertension

Biophysical profile

Noninvasive assessment of the fetus that includes fetal breathing movements, fetal movements, fetal tone, amniotic fluid index, and fetal heart rate patterns via a nonstress test Normal fetal biophysical activities indicate that the central nervous system is functional and that the fetus is not hypoxemic

RMP

Right mentoposterior

RMA

Right mentum anterior

ROA

Right occipitoanterior

ROP

Right occipitoposterior

ROT

Right occipitotransverse

Ovarian changes during pregnancy

a. A major function of the ovaries is to secrete progesterone for the first 6 to 7 weeks of pregnancy. b. The maturation of new follicles is blocked. c. The ovaries cease ovum production.

Cervical changes during pregnancy

a. Cervix becomes shorter, more elastic, and larger in diameter. b. Endocervical glands secrete a thick mucous plug, which is expelled from the canal when dilation begins. c. Increased vascularization and an increase in estrogen cause softening and a violet discoloration known as Chadwick's sign, which occurs at about 4 weeks of gestation.

Vaginal changes during pregnancy

a. Hypertrophy and thickening of the muscle occur. b. An increase in vaginal secretions is experienced; secretions are usually thick, white, and acidic.

Interventions for breast tenderness in pregnancy

a. Wearing a supportive bra b. Avoiding the use of soap on the nipples and areolar area to prevent drying of skin

Interventions for varicose veins in pregnancy

a. Wearing supportive stockings or support hose b. Elevating the feet when sitting c. Lying with the feet and hips elevated d. Avoiding long periods of standing or sitting e. Moving about while standing to improve circulation f. Avoiding leg crossing g. Avoiding constricting articles of clothing such as knee-high stockings

Gravidity

refers to the number of pregnancies

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, the priority nursing assessment is to check the: 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2. Blood pressure Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The physician should be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum assessment, option 2, blood pressure, is related specifically to the administration of this medication.

The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate? 1. Weak sucking response 2. Enlarged breast tissue 3. Soft skin 4. Vernix caseosa

2. Enlarged breast tissue It's common to see enlarged breast tissue in both male and female neonates in their first few days of life due to maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.

A client is in the second stage of labor. During this stage, how frequently should the nurse assess her uterine contractions? 1. Every 5 minutes 2. Every 15 minutes 3. Every 30 minutes 4. Every 60 minutes

2. Every 15 minutes During the second stage of labor, the nurse should assess the strength, frequency, and duration of contractions every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary. An interval of 30 to 60 minutes between assessments is too long because of variations in the length and duration of a client's labor.

The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first? 1. Obtain a thorough health history from the client. 2. Explore her own personal beliefs and feelings about contraception. 3. Help determine the most appropriate contraceptive method for the client. 4. Perform a complete physical assessment of the client.

2. Explore her own personal beliefs and feelings about contraception. The nurse must first explore her own personal beliefs and feelings about contraception to detect biases; if biases exist, the nurse must refer the client to another health care professional. Only after exploring personal beliefs and feelings does the nurse obtain a thorough health history, perform a complete physical assessment, and help determine the most appropriate contraceptive method.

A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time? 1. Teach the client progressive muscle relaxation. 2. Instruct the husband on touch, massage, and breathing patterns. 3. Use hypnosis on the client and her husband. 4. Teach the client and her husband about pain transmission.

2. Instruct the husband on touch, massage, and breathing patterns. If the unprepared client has a support person, the nurse should focus on that person's supporting role, demonstrating touch, massage, and simple breathing patterns. The other options are inappropriate at this time because they may make the client and her husband more anxious.

A pregnant client who's diabetic is at risk for having a large-for-gestational-age infant because of which of the following? 1. Excess sugar causing reduced placental functioning 2. Insulin acting as a growth hormone on the fetus 3. Maternal dietary intake of high calories 4. Excess insulin reducing placental functioning

2. Insulin acting as a growth hormone on the fetus Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.

A nurse is preparing to administer beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which of the following routes? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular

2. Intratracheal Respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. It is common in premature infants and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.

During an annual checkup, a client tells the nurse that she and her husband have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? 1. It should begin early in the third trimester and end 1 month after delivery. 2. It should begin before conception and end 3 months after delivery. 3. It should begin when the client learns she's pregnant and end after delivery. 4. It should begin at about 5 months' gestation and end at facility discharge.

2. It should begin before conception and end 3 months after delivery. Ideally, childbirth education should begin before conception (or as soon after conception as possible) and continue for about 3 months after delivery. Beginning childbirth education later and ending it earlier wouldn't provide enough time for optimal preparation of the client and her partner.

A nursing instructor is reviewing the menstrual cycle with a nursing student who will be conducting a prenatal teaching session. The instructor asks the student to describe the follicle-stimulating hormone (FSH) and the luteinizing hormone (LH). The student accurately responds by stating that: 1. FSH and LH are secreted by the adrenal glands. 2. FSH and LH are released from the anterior pituitary gland. 3. FSH and LH are secreted by the corpus luteum of the ovary. 4. FSH and LH stimulate the formation of milk during pregnancy.

2. FSH and LH are released from the anterior pituitary gland. Rationale: Follicle-stimulating hormone and luteinizing hormone, when stimulated by gonadotropin-releasing hormone from the hypothalamus, are released from the anterior pituitary gland to stimulate follicular growth and development, growth of the graafian follicle, and production of progesterone. Options 1, 3, and 4 are incorrect.

When caring for a client with preeclampsia, which action is a priority? 1. Monitoring the client's labor carefully and preparing for a fast delivery 2. Continually assessing the fetal tracing for signs of fetal distress 3. Checking vital signs every 15 minutes to watch for increasing blood pressure 4. Reducing visual and auditory stimulation

4. Reducing visual and auditory stimulation A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're of a lesser priority.

The nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises? 1. Tighten her stomach muscles 2. Lift both legs while lying down 3. Do pelvic squats 4. Stop the flow of urine while urinating

4. Stop the flow of urine while urinating By stopping urine flow during urination, the pelvic floor muscles are contracted. Tightening the leg or stomach muscles doesn't contract the pubococcygeus muscle. Pelvic squats don't tighten the pelvic floor muscles.

A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia . Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician? 1. Urinary output has increased. 2. Dependent edema has resolved. 3. Blood pressure reading is at the prenatal baseline. 4. The client complains of a headache and blurred vision.

4. The client complains of a headache and blurred vision. If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal signs.

A nurse is caring for four 1-day postpartum clients . Which client has an abnormal finding that would require further intervention? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/ min 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor

4. The client with lochia that is red and has a foul-smelling odor Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the physician to prescribe: 1. betamethasone (Celestone). 2. dinoprostone (Prepidil). 3. ergonovine (Ergotrate Maleate). 4. ritodrine (Yutopar).

4. ritodrine (Yutopar). Ritodrine, a beta-receptor agonist, is approved by the Food and Drug Administration for inhibition of preterm uterine contractions. Betamethasone is used to accelerate surfactant production in preterm labor. Dinoprostone is used to induce fetal expulsion and promote cervical dilation and softening. Ergonovine maleate is used to impede uterine blood flow — for example, in hemorrhage.

A client is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the client's risk of: 1. endometriosis. 2. female hypogonadism. 3. premenstrual syndrome. 4. tubal or ectopic pregnancy.

4. tubal or ectopic pregnancy. Women taking the minipill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female hypogonadism, and premenstrual syndrome aren't associated with progestin-only oral contraceptives.

Gestational hypertension

Blood pressure elevation detected first time after mid-pregnancy without proteinuria

Labor Stage 2

Cervical dilation is complete. Progress of labor is measured by descent of fetal head through the birth canal (change in fetal station). Uterine contractions occur every 2 to 3 minutes, lasting 60 to 75 seconds, and are of strong intensity. Increase in bloody show occurs. Mother feels urge to bear down; assist mother in pushing efforts.

Maternal insulin needs during the second and third trimesters

During the second and third trimesters, increases in placental hormones cause an insulin-resistant state, requiring an increase in the client's insulin dose.

GTPAL

G is gravidity, the number of pregnancies, including the present one. T is term births, the number born at term (longer than 37 weeks' gestation). P is preterm births, the number born before 37 weeks' gestation. A is abortions or miscarriages, the number of abortions or miscarriages L is the number of current living children.

Transient hypertension

Gestational hypertension with no signs of preeclampsia present at time of birth and hypertension resolves by 12 weeks after birth

Late decelerations

Late decelerations are nonreassuring patterns that reflect impaired placental exchange or uteroplacental insufficiency. The patterns look similar to early decelerations, but begin well after the contraction begins and return to baseline after the contraction ends. The degree of decline in FHR from baseline is not related to the amount of uteroplacental insufficiency.

Heartburn in pregnancy

Occurs in the second and the third trimesters Results from increased progesterone levels, decreased gastrointestinal motility, esophageal reflux, and displacement of the stomach by the enlarging uterus

Fetal lie

Relationship of the spine of the fetus to the spine of the mother Longitudinal or vertical - Fetal spine is parallel to the mother's spine. Fetus is in cephalic or breech presentation. Transverse or horizontal - Fetal spine is at a right angle, or perpendicular, to the mother's spine. Presenting part is the shoulder. Delivery by cesarean section is necessary.

Goodell's sign

Softening of the cervix that occurs at the beginning of the second month of gestation. This is considered a probable sign of pregnancy.

Bishop score

The Bishop score is used to determine maternal readiness for labor and evaluates cervical status and fetal position. The Bishop score is indicated before the induction of labor. The five factors are assigned a score of 0 to 3, and the total score is calculated. A score of 6 or more indicates a readiness for labor induction.

A client is admitted for an amniocentesis. Initial assessment findings include the following: 16 weeks pregnant, vital signs within normal limits, hemoglobin 12.2 gm, hematocrit 35%, and type O-negative blood. Which action would be most important to include in the client's care plan after the 20-minute amniocentesis has been completed? 1. Administer RhoGAM. 2. Check for rupture of membranes. 3. Assess uterine activity. 4. Provide additional fluid.

To prevent maternal sensitization, RhoGAM must be given after any invasive procedure on an Rh-negative client. All the other aspects are important but the administration of RhoGAM is the priority.

Syncope in pregnancy (when/cause)

Usually occurs in the first trimester; supine hypotension occurs particularly in the second and third trimesters May be triggered hormonally or caused by the increased blood volume, anemia, fatigue, sudden position changes, or lying supine

Interventions for hemorrhoids in pregnancy

a. Soaking in a warm sitz bath b. Sitting on a soft pillow c. Eating high-fiber foods and drinking sufficient fluids to avoid constipation d. Increasing exercise, such as walking e. Applying ointments, suppositories, or compresses as prescribed by the physician or nurse-midwife

Uterine changes during pregnancy

a. Uterus enlarges, increasing in mass from approximately 60 to 1000 g as a result of hyperplasia (influence of estrogen) and hypertrophy. b. Size and number of blood vessels and lymphatics increase. c. Irregular contractions occur.

During neonatal resuscitation immediately after delivery, chest compressions should be initiated when the heart rate falls below which of the following? 1. 60 beats/minute 2. 80 beats/minute 3. 100 beats/minute 4. 110 beats/minute

1. 60 beats/minute The normal neonatal heart rate is 120 to 160 beats/minute. Heart rates lower than 60 beats/minute necessitate chest compressions and ventilatory support.

Interventions for DIC

1. Remove underlying cause. 2. Monitor vital signs; assess for bleeding and signs of shock. 3. Prepare for oxygen therapy , volume replacement, blood component therapy, and possibly heparin therapy. 4. Monitor for complications associated with fluid and blood replacement and heparin therapy. 5. Monitor urine output and maintain at 30 mL/ hr (renal failure is a complication of DIC).

A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, the nurse expects to find: 1. a history of pelvic inflammatory disease. 2. grand multiparity (five or more births). 3. use of an intrauterine device for 1 year. 4. use of an oral contraceptive for 5 years.

1. a history of pelvic inflammatory disease. Pelvic inflammatory disease with accompanying salpingitis is commonly implicated in cases of tubal obstruction, the primary cause of ectopic pregnancy. Ectopic pregnancy isn't associated with grand multiparity or oral contraceptive use. Ectopic pregnancy is associated with use of an intrauterine device for 2 years or more.

When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be which of the following? 1. Shorter than her first labor 2. About half as long as her first labor 3. About the same length of time as her first labor 4. A length of time that can't be determined based on her first labor

2. About half as long as her first labor A woman having her second baby can anticipate a labor about half as long as her first labor. The other options are incorrect.

During the 6th month of pregnancy, a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the most likely cause of these symptoms? 1. A serious neurologic disorder 2. Eustachian tube vascularization 3. Increasing progesterone levels 4. An ear infection

2. Eustachian tube vascularization During pregnancy, increasing levels of estrogen — not progesterone — cause vascularization of the eustachian tubes, leading to such problems as earaches, impaired hearing, and a constant feeling of fullness in the ears. Nothing in the question implies that the client has a serious neurologic disorder or an ear infection.

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2. Hemorrhage In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa.

A client is receiving ergonovine (Ergotrate Maleate) to treat postpartum hemorrhage. When planning the client's care, the nurse anticipates monitoring for which common adverse reactions to ergonovine and other ergot alkaloids? 1. Abdominal cramps and diarrhea 2. Nausea and vomiting 3. Headache and facial flushing 4. Blurred vision and dizziness

2. Nausea and vomiting Nausea and vomiting are the most common adverse reactions to ergot alkaloids such as ergonovine. Less commonly, these drugs cause headache, dizziness, tinnitus, diaphoresis, palpitations, transient chest pain, and dyspnea.

A nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm , but that bleeding is excessive. Which of the following would be the initial nursing action? 1. Record the findings. 2. Notify the physician. 3. Massage the fundus. 4. Place the client in Trendelenburg's position.

2. Notify the physician. If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function . Although the nurse would record the findings , the initial nursing action would be to notify the physician.

A maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's prescriptions and would question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.

2. Obtain equipment for a manual pelvic examination. Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? 1. Shock 2. Disseminated intravascular coagulation 3. Hemorrhage 4. Infection

3. Hemorrhage A full bladder prevents the uterus from contracting completely, increasing the risk of hemorrhage. It doesn't directly increase the risk for shock, disseminated intravascular coagulation, or infection.

A client's husband asks the nurse whether he can do anything more to help his wife during labor. What should the nurse suggest? 1. Encourage her to talk during contractions. 2. Frequently ask her how she feels. 3. Provide helpful distractions. 4. Ask about the progress of other clients.

3. Provide helpful distractions. A partner can be most helpful to a client in labor by providing helpful distractions, timing contractions, coaching breathing, providing a calming influence, reducing loneliness, and communicating the client's needs to health care professionals. Encouraging her to talk and frequently asking her how she feels would be more of a hindrance than a help. Asking about the progress of other clients doesn't address his concerns about his wife.

Breast engorgement occurs on the 2nd or 3rd postpartum day in both breast-feeding and non-breast-feeding mothers. Which process causes engorgement? 1. The body's natural response following delivery 2. Nuzzling of the baby, which stimulates the let-down reflex 3. Vasodilation, which causes the breast to feel full 4. A reduction in estrogen levels

3. Vasodilation, which causes the breast to feel full Engorgement isn't caused by milk in the breasts but by increased blood levels from vasodilation. The body's natural response after delivery, nuzzling by the baby, and reduced estrogen levels contribute to milk production.

A nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? 1. "I should avoid straining during bowel movements." 2. "I can gently replace the hemorrhoids into the rectum." 3. "I can apply ice packs to the hemorrhoids to reduce the swelling." 4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."

4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." Measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners, ointments, or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs increase the blood flow to the area and worsen the discomfort from hemorrhoids.

A client is admitted to the maternity unit in active labor. Her cervix is dilated 4 cm. The physician prescribes etidocaine (Duranest), 150 mg via epidural catheter. What might account for the physician's choice of etidocaine over other local anesthetic agents? 1. It produces no vasoconstrictor effects. 2. It's least likely to cross the placenta. 3. It has the fastest onset of action. 4. It's least likely to cause cardiac arrhythmias.

2. It's least likely to cross the placenta. Etidocaine is least likely to cross the placenta. Local anesthetics, such as etidocaine, don't cause vasoconstriction. If vasoconstriction is needed, the local anesthetic must be combined with a drug such as epinephrine. Although etidocaine has an onset of action of 2 to 8 minutes, prilocaine's onset of action is less than 2 minutes. Local anesthetics, including etidocaine, can cause adverse cardiac arrhythmias if high doses are given.

Prevention of preterm births is vital for which of the following reasons? 1. It's costly to care for these babies. 2. It's the cause of more than half of the neonatal deaths in the United States. 3. These babies usually wind up with long-term health care needs. 4. These babies are usually mentally retarded.

2. It's the cause of more than half of the neonatal deaths in the United States. Prematurity is the leading cause of neonatal deaths in the United States; other industrialized nations have fewer premature births and fewer neonatal deaths than the United States does. Although the other three answers are complications of prematurity, prevention is the outcome nurses must focus on while providing care to their clients.

A nurse has developed a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which intervention as the highest priority? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

2. Monitoring the fetal heart rate Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.

When assessing a pregnant client with a history of cardiac dysfunction, the nurse discovers that the client has been taking propranolol (Inderal), a beta-adrenergic blocker, to treat hypertension. During labor, the nurse should stay alert for which adverse effect of this drug? 1. Uterine hypotonus 2. Uterine hypertonus 3. Hypotension 4. Tachyarrhythmias

2. Uterine hypertonus Propranolol, used to treat hypertension and tachyarrhythmias, may cause constant uterine hypertonus, resulting in preterm labor. It's unlikely that the drug would cause hypotension during labor, and it doesn't cause hypertension and tachyarrhythmias.

The nurse is recording an Apgar score for a neonate. The nurse should assess: 1. heart rate, respiratory effort, temperature, reflex irritability, and color. 2. heart rate, respiratory effort, reflex irritability, and color. 3. heart rate, respiratory effort, temperature, and color. 4. heart rate, respiratory effort, temperature, sucking reflex, and color.

2. heart rate, respiratory effort, reflex irritability, and color. When recording an Apgar score for a neonate, the nurse should assess heart rate, respiratory effort, reflex irritability, and color. The neonate's temperature and sucking reflex will be assessed shortly after birth but they aren't components of the Apgar score.

A woman who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characteristics or problems? 1. Fetal lung maturity 2. Gestational diabetes 3. Chromosomal defects 4. Neural tube defects 5. Polyhydramnios 6. Sex of the fetus

3. Chromosomal defects 4. Neural tube defects 6. Sex of the fetus In early pregnancy, amniocentesis can identify chromosomal defects and neural tube defects. It can also be used to determine the sex of the fetus. Amniocentesis can be used to evaluate fetal lung maturity only during the last trimester of pregnancy. A blood test performed between 24 and 28 weeks' gestation is used to screen for gestational diabetes. Ultrasound is used to identify polyhydramnios (excessive amount of amniotic fluid); amniocentesis can be used to treat polyhydramnios by removing excess fluid.

Before a postpartum client is discharged, the nurse checks her hormone levels. What happens to the level of human chorionic gonadotropin (hCG) during the postpartum period? 1. The circulating hCG level remains high for 2 to 4 weeks. 2. The serum hCG level diminishes over 6 weeks. 3. Circulating hCG disappears within 24 hours. 4. The serum hCG level remains high until the client's next pregnancy.

3. Circulating hCG disappears within 24 hours. Circulating hCG disappears within 8 to 24 hours after delivery in both lactating and nonlactating clients.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can the nurse best care for her clients during a fire alarm? 1. Permit the mothers and their neonates to continue sleeping. 2. Immediately evacuate the unit. 3. Close all of the doors on the unit. 4. Do nothing because it's most likely a fire drill.

3. Close all of the doors on the unit. The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.

The nurse notes that a neonate's skin appears ruddy 8 hours after birth. Which other sign would suggest that this neonate is in the second period of reactivity? 1. Thin oral secretions 2. Minimal response to stimuli 3. Labile heart rate 4. Regular respiratory rate

3. Labile heart rate The second period of reactivity is characterized by a labile heart rate with episodes of bradycardia and tachycardia, an exaggerated response to internal and external stimuli, thick oral secretions, an irregular respiratory rate, and ruddy skin. Minimal response to stimuli occurs during the neonate's sleep period.

A client tells the nurse that she wants to continue breastfeeding her toddler in addition to breastfeeding her neonate. The client's husband doesn't want her to continue breastfeeding the toddler because he thinks it will harm the neonate. Despite much discussion, the couple continues to disagree. Which health team member should the nurse consult to counsel the couple about breastfeeding issues? 1. Social worker 2. Home health nurse 3. Lactation consultant 4. Physician

3. Lactation consultant A lactation consultant can best address breastfeeding issues. The social worker could help the couple see each other's viewpoint, but has no breastfeeding training. The physician and home health nurse don't have specialized breastfeeding education.

When caring for a neonate, what is the most important step the nurse can take to prevent and control infection? 1. Assessing frequently for signs of infection 2. Using sterile technique for all caregiving 3. Practicing meticulous hand washing 4. Wearing gloves at all times

3. Practicing meticulous hand washing To prevent and control infection, the nurse should practice meticulous hand washing, scrubbing for 3 minutes before entering the nursery, washing frequently during caregiving activities, and scrubbing for 1 minute after providing care. Assessment for signs of infection can detect — not prevent — infection. The nurse should use sterile technique for invasive procedures, not all caregiving. The nurse should wear gloves whenever contact with blood or body fluids is possible.

A client is 2 months pregnant. Which factor should the nurse anticipate as least likely to affect her psychosocial transition during pregnancy? 1. Support from her partner 2. Whether the pregnancy was planned or unplanned 3. Previous health promotion activities 4. Previous parenting experiences

3. Previous health promotion activities Many factors can influence the smoothness of a pregnant client's psychosocial transition. Previous health promotion activities are least likely to affect this transition. The most important factors are support from her partner, parents, friends, and others; whether the pregnancy was planned or unplanned; and previous childbirth and parenting experiences. Age, socioeconomic status, sexuality concerns, birth stories of family members and friends, and past experiences with health care facilities and professionals may also influence a client's psychosocial transition during pregnancy.

The nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor? 1. Encouraging ambulation 2. Serving a nutritious diet 3. Promoting adequate hydration 4. Performing nipple stimulation

3. Promoting adequate hydration Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions.

A client with pregnancy-induced hypertension (PIH) probably exhibits which of the following symptoms? 1. Proteinuria, headaches, and vaginal bleeding 2. Headaches, double vision, and vaginal bleeding 3. Proteinuria, headaches, and double vision 4. Proteinuria, double vision, and uterine contractions

3. Proteinuria, headaches, and double vision A client with PIH complains of headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions aren't associated with PIH.

A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion if which of the following is noted on assessment of the client? 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Early decelerations of the fetal heart rate

3. Uterine hyperstimulation Oxytocin stimulates uterine contractions and is a common pharmacological method to induce labor. Adverse reactions associated with administration of the medication are hyperstimulation of uterine contractions and nonreassuring fetal heart rate patterns. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which of the following would be least likely if the neonate developed hemolytic disease? 1. Lethargy or irritability 2. Poor feeding patterns including vomiting 3. Weight loss greater than 10% 4. Signs of kernicterus

3. Weight loss greater than 10% Although weight loss may be greater than 10%, the most important assessments must include those addressing the problem of a rising bilirubin. Neonates who develop severe jaundice as a result of Rh and ABO incompatibility will exhibit lethargy or irritability and poor feeding patterns. If bilirubin levels are high enough to cross the blood brain barrier (usually 20 mg and higher), the neonate is at serious risk for neurologic impairment due to permanent cell damage (kernicterus).

Which finding is considered normal in the neonate during the first few days after birth? 1. Weight loss of 25% 2. Birth weight of 4½ to 5½ lb (2,000 to 2,500 g) 3. Weight loss then return to birth weight 4. Weight gain of 25%

3. Weight loss then return to birth weight Babies lose approximately 10% of their birth weight during the first 3 or 4 days, due to loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).

A nurse is assessing a newborn infant after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions is appropriate? 1. Contact the physician. 2. Apply gentle pressure. 3. Reinforce the dressing. 4. Document the findings.

4. Document the findings. The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the physician. Because the findings identified in the question are normal, the nurse would document the assessment findings.

A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation? 1. Keeping him away from drafts 2. Putting a blanket between him and cold surfaces 3. Putting a cap on his head 4. Drying him thoroughly after a bath

4. Drying him thoroughly after a bath Babies lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss due to evaporation. Keeping a baby away from drafts prevents heat loss due to convection. Keeping a baby off a cold surface, such as a scale, prevents the loss of heat due to conduction. Placing a cap on the baby's head preserves heat and prevents heat loss due to radiation.

Miss Fox is a single woman who is 15 weeks pregnant. This is her first prenatal visit and she explains she does not have insurance and cannot afford to pay the bill. What would be the most helpful thing you could tell her? incorrect 1. Offer to treat her anyway, but just this one time. incorrect 2. Tell her to sign up for health insurance and to return when she has it. incorrect 3. Tell her there is nothing you can do if she cannot pay her bill. 4. Explain the variety of programs instituted by the federal government

4. Explain the variety of programs instituted by the federal government Ongoing prenatal care is vital to a healthy pregnancy and birth. To this end, the federal government has instituted a variety of programs for maternal child care about which you could offer her information. It would not be as helpful to offer to treat her once or to tell her to sign up for insurance.

The nurse is caring for a client in labor. Which assessment finding indicates fetal distress? 1. Lack of meconium staining 2. Early decelerations in fetal heart rate during contractions 3. An increase in fetal heart rate with fetal scalp stimulation 4. Fetal blood pH less than 7.2

4. Fetal blood pH less than 7.2 A fetal blood pH less than 7.2 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.2 to 7.3 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. The other options are all normal findings.

The nurse recognizes that labor is divided into how many stages? 1. Five 2. Three 3. Two 4. Four

4. Four Labor is divided into four stages: first stage, onset of labor to full dilation; second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour postpartum. The first stage is divided into three phases: early, active, and transition.

A client is resting comfortably 4 hours after delivering her first child. When measuring her heart rate, the nurse expects which normal finding? 1. A thready pulse 2. An irregular pulse 3. Tachycardia 4. Bradycardia

4. Bradycardia During the client's first postpartum rest or sleep, which usually occurs 2 to 4 hours after delivery, the heart rate typically decreases, possibly slowing to 50 beats/minute (bradycardia). This probably results from supine positioning and such normal physiologic phenomena as the postpartum rise in stroke volume and a reduction in vascular bed size. An irregular pulse is never normal. Tachycardia may indicate excessive blood loss, especially if accompanied by a thready pulse and such other signs as pallor, an increased respiratory rate, and diaphoresis.

During the early postpartum period, the nurse is evaluating a client's attachment to her neonate. Which type of parent has the most difficulty forming an attachment to a neonate? 1. One with little knowledge of parent-neonate attachment 2. One who lost a job recently 3. One who is an only child 4. One whose parent died recently

4. One whose parent died recently A person in the process of detachment, which is necessary after a parent's death, may have difficulty forming an attachment to a neonate. To promote parent-neonate attachment, the nurse must be aware of recent family events. The nurse can overcome a parent's lack of knowledge about attachment through teaching and by providing the appropriate environment. Although job loss is stressful, it's less of a barrier to attachment than parental loss. Being an only child has little or no effect on one's ability to form an attachment with a neonate.

What key psychosocial tasks must a woman accomplish during the third trimester? 1. Resolving grief over the loss of old roles 2. Developing a mother image 3. Coping with common discomforts and changes 4. Overcoming fears she may have about the unknown, loss of control, and death

4. Overcoming fears she may have about the unknown, loss of control, and death During the third trimester, a key psychosocial task is to overcome fears the woman may have about the unknown, labor pain, loss of self-esteem, loss of control, and death. During the first trimester, the mother copes with the common discomforts and changes. During the second trimester, psychosocial tasks include mother-image development, coping with body image and sexuality changes, and prenatal bonding.

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage . Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

4. Peripheral vascular disease Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage . Ergot alkaloids are contraindicated in clients with significant cardiovascular disease , peripheral vascular disease, hypertension, preeclampsia , or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids.

A nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following assessment findings would alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal heart rate

4. Persistent nonreassuring fetal heart rate Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis , and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

Which drug will the physician probably order to treat a pregnant client who is experiencing morning sickness? 1. Prochlorperazine (Compazine) 2. Diphenhydramine (Benadryl) 3. Trimethobenzamide (Tigan) 4. Phosphorated carbohydrate solution (Emetrol)

4. Phosphorated carbohydrate solution (Emetrol) The physician will probably order phosphorated carbohydrate solution for a pregnant client who is experiencing morning sickness. Prochlorperazine, diphenhydramine, and trimethobenzamide may produce congenital anomalies and aren't recommended to treat morning sickness caused by pregnancy.

When assessing a client 1 hour after vaginal delivery, the nurse notes blood gushing from the vagina, pallor, and a rapid, thready pulse. What do these findings suggest? 1. Uterine involution 2. Cervical laceration 3. Placental separation 4. Postpartum hemorrhage

4. Postpartum hemorrhage Postpartum hemorrhage results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. Placental separation causes a sudden gush or trickle of blood from the vagina, rise of the fundus in the abdomen, increased umbilical cord length at the introitus, and a globe-shaped uterus. Uterine involution causes a firmly contracted uterus, which can't occur until the placenta is delivered. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus.

Which statement is not a contributory factor to thermoregulation in the preterm neonate? 1. Immature central nervous system (CNS) 2. Large skin surface area 3. Lack of subcutaneous (S.C.) and brown fat 4. Tendency toward capillary fragility

4. Tendency toward capillary fragility Tendency toward capillary fragility has nothing to do with thermoregulation. The hypothalamus is the site of temperature regulation. In preterm neonates, the CNS is poorly developed, so these neonates may be more prone to temperature instability. The large skin surface area provides the perfect medium for heat loss through evaporation and convection. Lack of S.C. and brown fat are also contributors to temperature instability. Without S.C. fat, there is nothing to insulate the neonate from heat loss. Brown fat provides calories that help with heat production.

A client who has been in the latent phase of the first stage of labor enters the transition to the active phase. During the transition, the nurse expects to see which client behavior? 1. A desire for personal contact and touch 2. A full response to teaching 3. Fatigue, a desire for touch, and quietness 4. Withdrawal, irritability, and resistance to touch

4. Withdrawal, irritability, and resistance to touch During the transition to the active phase of the first stage of labor, increased pain typically makes the client withdrawn, irritable, and resistant to touch. During the latent phase (the early part of the first stage of labor), when contractions aren't intensely painful, the client typically desires personal contact and touch and responds to teaching and interventions. Fatigue, a desire for touch, and quietness are common during the third and fourth stages of labor.

When preparing a postpartum client for discharge, the nurse teaches her about warning signs during the postpartum period. The nurse should instruct her to report: 1. scant lochia alba 2 to 3 weeks after delivery. 2. a temperature of 99.7° F (37.6° C) for 24 hours or more. 3. breast tenderness that is relieved by analgesics. 4. a red, warm, painful area in the breast.

4. a red, warm, painful area in the breast. Postpartum warning signs include a red, warm, painful area in either breast; heavy vaginal bleeding or passage of clots or tissue fragments; and a temperature of 100.2° F (37.9° C) or higher for 24 hours or longer. Scant lochia alba 2 to 3 weeks after delivery, a temperature of 99.7° F (37.6° C) for 24 hours or more, and breast tenderness that is relieved by analgesics are normal postpartum findings.

The nurse assesses a client for evidence of postpartum hemorrhage during the third stage of labor. Early signs of this postpartum complication include: 1. an increased pulse rate, decreased respiratory rate, and increased blood pressure. 2. a decreased pulse rate, increased respiratory rate, and increased blood pressure. 3. a decreased pulse rate, decreased respiratory rate, and increased blood pressure. 4. an increased pulse rate, increased respiratory rate, and decreased blood pressure.

4. an increased pulse rate, increased respiratory rate, and decreased blood pressure. An increased pulse rate followed by an increased respiratory rate and decreased blood pressure may be the first signs of postpartum hemorrhage and hypovolemic shock.

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if: 1. the neonate voids once or twice every 24 hours. 2. the neonate breast-feeds four times in 24 hours. 3. the neonate loses 10% to 15% of the birth weight within the first 2 days after birth. 4. the neonate latches onto the areola and swallows audibly.

4. the neonate latches onto the areola and swallows audibly. Breast-feeding is effective if the infant latches onto the mother's areola properly and if swallowing is audible. A breast-feeding neonate should void at least 6 to 8 times per day and should breast-feed every 2 to 3 hours. Over the first few days after birth, an acceptable weight loss is 5% to 10% of the birth weight.

The nurse is caring for a client after evacuation of a hydatidiform molar pregnancy. The nurse should tell the woman to: 1. wait 1 month before trying to become pregnant again. 2. make an appointment for follow-up human chorionic gonadotropin (HCG) level monitoring at the end of 1 year. 3. discuss options for sterilization with the physician. 4. use birth control for at least 1 year.

4. use birth control for at least 1 year. After experiencing a hydatidiform molar pregnancy, the client should be counseled to use a reliable method of birth control for at least 1 year. Because of the risk of choriocarcinoma, her HCG levels need to be monitored monthly for 1 to 2 years. Sterilization isn't necessary after hydatidiform mole. If HCG levels remain low, a woman may try to become pregnant after 1 year. The risk of recurrence of a hydatidiform mole is low.

Reactive Nonstress Test

"Reactive" indicates a healthy fetus. The result requires two or more FHR accelerations of at least 15 beats/ min, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period.

Positive Contraction Stress Test

(Abnormal) A positive result is represented by late decelerations of FHR, with 50% or more of the contractions in the absence of hyperstimulation of the uterus.

Negative Contraction Stress Test

(Normal) A negative result is represented by no late decelerations of fetal heart rate (FHR).

Calorie/day increase needed during pregnancy

300 cal/day

Calorie/day increase needed during lactation

500 cal/day

Hydatidiform mole

A form of gestational trophoblastic disease that occurs when the trophoblasts, which are the peripheral cells that attach the fertilized ovum to the uterine wall, develop abnormally. The mole manifests as an edematous grape-like cluster that may be nonmalignant or may develop into choriocarcinoma.

Minus station

Above ischial spine

Station 0

At ischial spine

CHORIOAMNIONITIS

Bacterial infection of the amniotic cavity; can result from premature rupture of the membranes, vaginitis, amniocentesis, or intrauterine procedures May result in the development of postpartum endometritis

Nonreassuring FHR Patterns

Bradycardia Tachycardia Late decelerations Prolonged decelerations Hypertonic uterine activity Decreased or absent variability Variable decelerations falling to less than 70 beats/ min for longer than 60 seconds

Stage 1: Active phase

Cervical dilation is 4 to 7 cm. Uterine contractions occur every 3 to 5 minutes, are 30 to 60 seconds in duration, and are of moderate intensity.

Stage 1: Transition phase

Cervical dilation is 8 to 10 cm. Uterine contractions occur every 2 to 3 minutes, are 45 to 90 seconds in duration, and are of strong intensity.

Changes in the skeletal system during pregnancy

Changes in the center of gravity begin in the second trimester and are caused by the hormones relaxin and progesterone. During pregnancy, postural changes occur as the increased weight of the uterus causes a forward pull of the bony pelvis. It is important for the nurse to encourage the client to implement measures that maintain correct posture to prevent a backache.

Hegar's sign

Compressibility and softening of the lower uterine segment that occurs at about week 6 of gestation. This is considered a probable sign of pregnancy.

Vas deferens

Connects the epididymis with the prostate. Joins with ejaculatory ducts and squeezes mature sperm from the epididymis into the urethra. This is the structure that is cauterized or incised during a vasectomy.

True Labor

Contractions occur regularly, become stronger, last longer, and occur closer together. Cervical dilation and effacement are progressive. The fetus usually becomes engaged in the pelvis and begins to descend.

Labor Stage 3

Contractions occur until the placenta is expelled. Placental separation and expulsion occur. Expulsion of the placenta occurs 5 to 30 minutes after the birth of the infant. Schultze mechanism: Center portion of the placenta separates first, and its shiny fetal surface emerges from the vagina. Duncan mechanism: Margin of the placenta separates , and the dull, red, rough maternal surface emerges from the vagina first.

Epididymis

Convoluted tubule that stores sperm after maturation. The epididymis can store sperm up to 42 days.

Complete abortion

Loss of all products of conception occurs

Eclampsia

Occurrence of seizures in a preeclamptic woman

Labor Stage 4

Period 1 to 4 hours after delivery Blood pressure returns to prelabor level. Pulse is slightly lower than during labor. Fundus remains contracted, in the midline, 1 or 2 fingerbreadths below the umbilicus.

Four P's

Powers Passageway Passenger Psyche

Luteinizing hormone (males)

Produced by: Anterior pituitary Target: Testes Stimulates Leydig cells to secrete testosterone

Follicle stimulating hormone (males)

Produced by: Anterior pituitary Target: Testes Stimulates sperm formation

Gonadotropin releasing hormone (males)

Produced by: Hypothalamus Target: Anterior pituitary Stimulates release of FSH and LH Initiates puberty

Testosterone (males)

Produced: Adrenal glands and ovaries Target: Male sexual organs Development of male sex organs in fetus Growth and division of cells that mature sperm Development of secondary male sex characteristics

Missed abortion

Products of conception are retained in utero after fetal death

Zidovudine (Retrovir)

Recommended for the prevention of maternal-to-fetal HIV transmission and is administered orally beginning after 14 weeks' gestation, intravenously during labor, and in the form of syrup to the newborn for 6 weeks after birth.

Habitual abortion

Spontaneous abortions occur in three or more successive pregnancies

Inevitable abortion

Spotting and cramping occur and cervix begins to dilate and efface

Threatened abortion

Spotting and cramping without cervical change occur

Stage 1 : Latent Phase

Stage 1 is the longest. A labor curve, often called a Friedman curve, may be used to identify whether a woman's cervical dilation is progressing at the expected rate Cervical dilation is 1 to 4 cm. Uterine contractions occur every 15 to 30 minutes, are 15 to 30 seconds in duration, and are of mild intensity.

Quickening

The first perception of fetal movement by the mother may occur the sixteenth to twentieth week of gestation.

Station

The measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine

Risks for newborn of a diabetic mother

The newborn of a diabetic mother is at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia, and congenital anomalies.

The nurse is providing teaching to a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day?

The recommended energy intake for a lactating mother is 500 kcal more than their nonpregnant intake.

Presenting part

The specific fetal structure lying nearest to the cervix

Induced abortion

Therapeutic or elective reasons exist for terminating pregnancy

Hemorrhoids in pregnancy

Usually occur in the second and the third trimesters Result from increased venous pressure and constipation

Varicose veins in pregnancy

Usually occur in the second and the third trimesters Result from weakening walls of the veins or valves and venous congestion

Urinary urgency and frequency in pregnancy (when/cause)

Usually occurs in the first and third trimesters Caused by pressure of the uterus on the bladder

Engagement

When the widest diameter of the presenting part has passed the inlet; usually corresponds to a 0 station

Multigravida

a woman in at least her second pregnancy

Newborns and HIV

a. Neonates born to HIV-positive clients may test positive because antibodies received from the mother may persist for 18 months after birth; all neonates acquire maternal antibody to HIV infection, but not all acquire infection. b. The use of antiviral medication, reduced exposure of the neonate to maternal blood and body fluids , and early identification of HIV in pregnancy reduce the risk of transmission to the neonate.

Major concerns related to adolescent pregnancy

poor nutritional status emotional and behavioral difficulties lack of support systems increased risk of stillbirth low-birth-weight infants fetal mortality cephalopelvic disproportion increased risk of maternal complications, such as hypertension, anemia, prolonged labor, and infections

Parity

the number of births (not the number of fetuses, e.g., twins) carried past 20 weeks ' gestation, whether or not the fetus was born alive

DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

DIC is a maternal condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation

Nonstress test

Test is performed to assess placental function and oxygenation. Test determines fetal well-being. Test evaluates fetal heart rate (FHR) response to fetal movement.

Interventions for syncope in pregnancy

a. Sitting with the feet elevated b. Changing positions slowly **The nurse needs to instruct the pregnant woman to avoid lying in the supine position, particularly in the second and third trimesters. The supine position places the woman at risk for supine hypotension, which occurs as a result of pressure of the uterus on the inferior vena cava.

Interventions for vaginal discharge in pregnancy

a. Using proper cleansing and hygiene techniques b. Wearing cotton underwear c. Avoiding douching d. Consulting the physician or nurse-midwife if infection is suspected

Which of the following factors influence the decrease in maternal mortality in the United States? Select all that apply. 1. Availability of high-risk maternal-infant care centers 2. Delivery by a CNM 3. Use of a specialized antepartum maternity clinic 4. Home delivery

1. Availability of high-risk maternal-infant care centers 3. Use of a specialized antepartum maternity clinic

Pregnancy and the cardiovascular system

1. Circulating blood volume increases, plasma increases, and total red blood cell volume increases (total volume increases by approximately 40% to 50%). 2. Physiological anemia occurs as the plasma increase exceeds the increase in production of red blood cells. 3. Iron requirements are increased. 4. Heart size increases, and the heart is elevated slightly upward and to the left because of displacement of the diaphragm as the uterus enlarges 5. Retention of sodium and water may occur.

When determining maternal and fetal well-being, which assessment is least important? 1. Signs of orthostatic hypotension 2. Fetal heart rate and activity 3. The mother's acceptance of growing fetus 4. Signs of facial or digital edema

1. Signs of orthostatic hypotension Orthostatic hypotension doesn't occur until late in the pregnancy and is easily correctable. Collection of other assessment data, such as fetal heart rate and activity, the mother's acceptance of the growing fetus, and signs of edema, should be started early in the pregnancy because abnormalities can put the mother or the fetus at risk for significant physiologic and psychological problems.

A woman who's 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should: 1. recognize these as normal early pregnancy signs and symptoms. 2. question her further about these signs and symptoms. 3. tell her that she'll need blood work and urinalysis. 4. tell her that she may be excessively worried.

1. recognize these as normal early pregnancy signs and symptoms. Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine if this method of family planning would be appropriate? 1. "Has either of you ever had surgery?" 2. "Do you plan to have any other children?" 3. "Does either of you have diabetes mellitus?" 4. "Does either of you have problems with high blood pressure?"

2. "Do you plan to have any other children?" Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure.

he nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones? 1. 7 weeks 2. 11 weeks 3. 17 weeks 4. 21 weeks

2. 11 weeks Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation.

The nurse is assisting in developing a teaching plan for a client who's about to enter the third trimester of pregnancy. The teaching plan should include identification of which danger sign that must be reported immediately? 1. Hemorrhoids 2. Blurred vision 3. Dyspnea on exertion 4. Increased vaginal mucus

2. Blurred vision During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they don't require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.

If an ethical dilemma regarding treatment arises in care of a pregnant woman at 16 weeks' gestation, what factors will be considered in the decision-making process? 1. The rights of the fetus take precedence. 2. The rights of the mother are paramount. 3. The fetus is legally viewed as a nonperson. 4. The courts resolve all issues of maternal-fetal conflict.

2. The rights of the mother are paramount. Sixteen weeks is prior to viability. Abortion can be performed until the period of viability. After that time, abortion is permissible only when the life or health of the mother is threatened. Before viability, the rights of the mother are paramount; after viability, the rights of the fetus take precedence. Court intervention should be considered a last resort, appropriate only in extraordinary circumstances. Advances in technology have permitted the physician to treat the fetus and monitor fetal development. The fetus is increasingly viewed as a client separate from the mother, and is no longer legally viewed as a nonperson.

A client with pregnancy-induced hypertension (PIH) receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client? 1. To lower blood pressure 2. To prevent seizures 3. To inhibit labor 4. To block dopamine receptors

2. To prevent seizures Magnesium sulfate is given to prevent and control seizures in clients with PIH. Beta-adrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors.

A nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding that necessitates further testing? 1. Quickening 2. Braxton Hicks contractions 3. Fetal heart rate of 180 beats/ min 4. Consistent increase in fundal height

3. Fetal heart rate of 180 beats/ min The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/ min in the first trimester and slows with fetal growth . Near and at term, the fetal heart rate ranges from 120 to 160 beats/ min. Options 1, 2, and 4 are normal expected findings.

A pregnant client asks a nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which of the following weeks of gestation? 1. 6 and 8 2. 8 and 10 3. 10 and 12 4. 16 and 20

4. 16 and 20 Quickening is fetal movement and may occur by the 16 to 20 week's gestation. The expectant mother first notices subtle fetal movements during this time, which gradually increase in intensity. Options 1, 2, and 3 are incorrect time frames because quickening does not occur this early during pregnancy.

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. The nurse tells the client that: 1. Total abstinence from sexual intercourse is necessary during the entire pregnancy. 2. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. 3. Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy. 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.

4. A cesarean section will be necessary if vaginal lesions are present at the time of labor. For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. The safety of acyclovir has not been established during pregnancy, and it should be used only when a life-threatening infection is present. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, clients should continue to abstain until they become culture -negative because prolonged viral shedding may occur in such cases. Keeping the genital area clean and dry promotes healing.

After determining that a pregnant client is Rh-negative, the physician orders an indirect Coombs' test. What is the purpose of performing this test in a pregnant client? 1. To determine the fetal blood Rh factor 2. To determine the maternal blood Rh factor 3. To detect maternal antibodies against fetal Rh-negative factor 4. To detect maternal antibodies against fetal Rh-positive factor

4. To detect maternal antibodies against fetal Rh-positive factor The indirect Coombs' test measures the number of antibodies against fetal Rh-positive factor in maternal blood. The maternal blood Rh factor is determined before the indirect Coombs' test is done. No maternal antibodies against fetal Rh-negative factor exist.

ballottement

Rebounding of the fetus against the examiner's finger on palpation. When the examiner taps the cervix, the fetus floats upward in the amniotic fluid. The examiner feels a rebound when the fetus falls back.

Chadwick's sign

Violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about 4 weeks of pregnancy caused by increased vascularity. This is considered a probable sign of pregnancy.

Primipara

a woman who has had one birth that occurred after the twentieth week of gestation

Multipara

a woman who has had two or more pregnancies to the stage of fetal viability

Nulligravida

a woman who has never been pregnant

Primigravida

a woman who is pregnant for the first time

Fundal height

measured to evaluate the gestational age of the fetus.\ During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals fetal age in weeks ± 2 cm At 16 weeks, the fundus can be found approximately halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is approximately at the location of the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of Goodell's sign. The nurse determines that this sign indicates: 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus

1. A softening of the cervix At the beginning of the second month of gestation, the cervix becomes softer as a result of increased vascularity and hyperplasia, which cause Goodell's sign. Cervical softening is noted by the examiner during pelvic examination . Goodell's sign does not indicate the presence of fetal movement. Human chorionic gonadotropin noted in maternal urine is a probable sign of pregnancy. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulating through the placenta.

A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, maintains the body temperature of the fetus, and helps assess kidney function because it contains urine from the fetus. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.

he nurse is assessing a client who's 6 weeks pregnant. Which findings best support a suspicion of ectopic pregnancy? 1. Amenorrhea and adnexal fullness and tenderness 2. Nausea, vomiting, and slight uterine enlargement 3. Grapefruit-size uterine enlargement and vaginal spotting 4. Amenorrhea, sudden weight gain, and audible fetal heart tones above the symphysis pubis

1. Amenorrhea and adnexal fullness and tenderness Signs and symptoms of ectopic pregnancy include amenorrhea and adnexal fullness and tenderness. Nausea, vomiting, and vaginal spotting may occur in ectopic pregnancy, but the uterus doesn't enlarge because it remains empty. Weight gain may accompany ectopic pregnancy; however, fetal heart tones aren't audible above the symphysis pubis in clients with this disorder.

Which of the following would the nurse expect to assess as presumptive signs of pregnancy ? 1. Amenorrhea and quickening 2. Uterine enlargement and Chadwick's sign 3. A positive pregnancy test and a fetal outline 4. Braxton Hicks contractions and Hegar's sign

1. Amenorrhea and quickening Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators — for example, Chadwick's sign, Hegar's sign, a positive pregnancy test, uterine enlargement, and Braxton Hicks contractions. Positive signs and objective indicators such as fetal outline on ultrasound confirm pregnancy.

A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should do which of the following? 1. Ask her to void. 2. Instruct her to drink 1 L of fluid. 3. Prepare her for I.V. anesthesia. 4. Place her on her left side.

1. Ask her to void. To prepare a client for amniocentesis, the nurse should ask her to empty her bladder to reduce the risk of bladder perforation. Before transabdominal ultrasound, the nurse may instruct the client to drink 1 L of fluid to fill the bladder (unless ultrasound is done before amniocentesis to locate the placenta). I.V. anesthesia isn't given for amniocentesis. The client should be supine during the procedure; afterward, she should be placed on her left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output.

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which of the following are probable signs of pregnancy ? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation , active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.

A client who's pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she's apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing: 1. Braxton Hicks contractions. 2. back labor. 3. fetal distress. 4. true labor contractions.

1. Braxton Hicks contractions. Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout pregnancy, they're most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3 to 4 months in multiparous clients. Back labor refers to pain that typically starts in the back. Fetal distress doesn't cause contractions, although it may cause sharp abdominal pain. Decreased or absent fetal movements, green-tinged or yellowish green-tinged fluid, or port-wine-colored fluid may also indicate fetal distress. Pain from true labor contractions typically starts in the back and moves to the front of the fundus as a band of pressure that peaks and subsides in a regular pattern.

During each prenatal checkup, the nurse obtains the client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup? 1. Evaluating the client for edema 2. Measuring the client's hemoglobin (Hb) level 3. Obtaining pelvic measurements 4. Determining the client's Rh factor

1. Evaluating the client for edema During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of pregnancy-induced hypertension (PIH). If edema exists, the nurse should assess for high blood pressure and proteinuria — other signs of PIH. Hb is measured during the first prenatal visit and again at 24 to 28 weeks' gestation and at 36 weeks' gestation. The pelvis is measured and the Rh factor determined during the first prenatal visit.

Positive signs (diagnostic) of pregnancy

1. Fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation 2. Active fetal movements palpable by examiner 3. Outline of fetus via radiography or ultrasonography

The nurse prepares a client who's 28 weeks pregnant for a nonstress test (NST). Which intervention is most likely to stimulate fetal movements during this test? 1. Having the client drink orange juice 2. Instructing the client to brush her hand over a nipple 3. Advising the client not to eat for 12 hours before the test 4. Positioning the client on her left side

1. Having the client drink orange juice The NST measures fetal movement and the fetal heart rate. To stimulate fetal movement, the nurse may instruct the client to drink a liquid, such as orange juice, or to touch or rock her abdomen to move the fetus. Brushing a hand over a nipple or positioning the client on her left side wouldn't stimulate fetal movement. The client should have a snack before the test to help ensure readable fetal movements.

A pregnant client at 32 weeks' gestation has mild preeclampsia. She is discharged home with instructions to remain on bed rest. She should also be instructed to call her doctor if she experiences which symptoms? 1. Headache 2. Increased urine output 3. Blurred vision 4. Difficulty sleeping 5. Epigastric pain 6. Severe nausea and vomiting

1. Headache 3. Blurred vision 5. Epigastric pain 6. Severe nausea and vomiting Headache, blurred vision, epigastric pain, and severe nausea and vomiting can indicate worsening maternal disease. Decreased, not increased, urine output is a concern because it could indicate renal impairment. Difficulty sleeping, a common complaint during the third trimester, is only a concern if it's caused by any of the other symptoms.

The nurse is assessing a client who's 29 weeks pregnant. What is the least invasive and demanding method for assessing fetal well-being? 1. Maternal fetal activity count 2. Chorionic villi sampling 3. Ultrasonography 4. Nonstress test

1. Maternal fetal activity count Maternal fetal activity count is the least invasive and demanding method for assessing fetal well-being. To use this method, the client simply counts, records, and reports the number of times the fetus kicks during a designated period each day. Chorionic villi sampling is invasive and expensive and should be reserved for pregnant clients at risk for genetic defects. Ultrasonography and nonstress testing, although noninvasive, are expensive and require the use of medical facilities, which may place extra demands on the client's time.

A nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/ min. On the basis of this finding, the appropriate nursing action is to: 1. Notify the physician. 2. Document the finding. 3. Check the mother's heart rate. 4. Tell the client that the fetal heart rate is normal.

1. Notify the physician. Rationale: The fetal heart rate (FHR) depends on gestational age and ranges from 160 to 170 beats/ min in the first trimester, but slows with fetal growth to 120 to 160 beats/ min near or at term. At or near term, if FHR is less than 120 beats/ min or more than 160 beats/ min with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the physician. Options 3 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the physician needs to be notified.

A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take first? 1. Place the client on her left side and start supplemental oxygen, as ordered, to maximize fetal oxygenation. 2. Administer I.V. oxytocin, as ordered, to stimulate uterine contractions and prevent further hemorrhage. 3. Ease the client's anxiety by assuring her that everything will be all right. 4. Massage the client's fundus to help control the hemorrhage.

1. Place the client on her left side and start supplemental oxygen, as ordered, to maximize fetal oxygenation. The client's signs and symptoms indicate abruptio placentae, which decreases fetal oxygenation. To maximize fetal oxygenation, the nurse should place the client on her left side to increase placental blood flow to the fetus and administer supplemental oxygen, as ordered, to increase the blood oxygen level. Administering oxytocin isn't appropriate because this drug stimulates contractions, which further reduce fetal oxygenation. The nurse can't assure the client that everything will be all right, only that everything possible will be done to help her and her fetus. Fundal massage is used only during the postpartum period to control hemorrhage.

A client who is 14 weeks pregnant states, "Ever since I've been pregnant, I've had a hard time moving my bowels." Increased levels of what hormone are responsible for this common discomfort of pregnancy? 1. Progesterone 2. Testosterone 3. Estrogen 4. Human chorionic gonadotropin

1. Progesterone Progesterone increases smooth muscle relaxation, thereby decreasing peristalsis. This slowed movement of contents through the GI system can lead to firmer stools and constipation. Testosterone, estrogen, and human chorionic gonadotropin don't cause constipation.

A client is in the 38th week of her first pregnancy. She calls the prenatal facility to report occasional tightening sensations in the lower abdomen and pressure on the bladder from the fetus, which she says seems lower than usual. The nurse should take which action? 1. Review premonitory signs of labor with the client. 2. Instruct the client to go the health care facility for a nonstress test (NST). 3. Ask the client to bring in a urine specimen for urinalysis. 4. Make an appointment for the client to see the physician today.

1. Review premonitory signs of labor with the client. Because the client is describing two premonitory signs of labor, Braxton Hicks contractions and tightening, the nurse should review these normal signs and reassure the client. An NST, used to assess fetal well-being, would be inappropriate unless the client reported changes in fetal activity. Urinalysis wouldn't be indicated unless the client reported symptoms of bladder inflammation, such as dysuria or urinary frequency or urgency. Because the client's findings are normal, she need not see the physician other than at her regular weekly appointment.

A client who's 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Of the following nursing diagnoses, the nurse should give the highest priority to: 1. Risk for deficient fluid volume. 2. Anxiety. 3. Acute pain. 4. Impaired gas exchange.

1. Risk for deficient fluid volume. A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but fluid volume loss through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss.

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse understands that the client should be able to find out at 12 weeks' gestation because by the end of the twelfth week: 1. The sex of the fetus can be determined by the appearance of the external genitalia. 2. The sex of the fetus can be determined because the external genitalia begins to differentiate. 3. The sex of the fetus can be determined because the testes are descended into the scrotal sac. 4. The sex of the fetus can be determined because the internal differences in males and females become apparent.

1. The sex of the fetus can be determined by the appearance of the external genitalia. Rationale: By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Option 2 (differentiation of the external genitalia) occurs at the end of the ninth week. Option 3 occurs at the end of the thirty-eighth week (testes descend into the scrotal sac). Option 4 occurs at the end of the seventh week (internal differences in the male and female).

Probable signs of pregnancy

1. Uterine enlargement 2. Hegar's sign: Compressibility and softening of the lower uterine segment that occurs at about week 6 3. Goodell's sign: Softening of the cervix that occurs at the beginning of the second month 4. Chadwick's sign: Violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4 5. Ballottement: Rebounding of the fetus against the examiner's fingers on palpation 6. Braxton Hicks contractions (irregular painless contractions that may occur intermittently throughout pregnancy) 7. Positive pregnancy test for determination of the presence of human chorionic gonadotropin

A low-risk client who's 6 weeks pregnant comes to the clinic for her first prenatal visit. At this time, the nurse should assign highest priority to: 1. establishing a schedule of prenatal visits. 2. scheduling an ultrasound test to confirm the pregnancy. 3. enrolling the client in a childbirth class. 4. scheduling genetic testing for the client.

1. establishing a schedule of prenatal visits. To promote the health of the client and her fetus, the nurse should establish a regular schedule of prenatal visits. Pregnancy is confirmed by serum human chorionic gonadotropin levels, not ultrasonography. The client undergoes ultrasonography to evaluate fetal growth and well-being; this procedure yields different information from one trimester to the next. Childbirth education classes can start at any time during pregnancy. Although the nurse may encourage enrollment, the client decides when to enroll. Genetic testing isn't necessary for a low-risk client.

A client, age 39, visits the nurse practitioner for a regular prenatal check-up. She's 32 weeks pregnant. When assessing her, the nurse should stay especially alert for signs and symptoms of: 1. pregnancy-induced hypertension (PIH). 2. iron deficiency anemia. 3. cephalopelvic disproportion. 4. sexually transmitted diseases (STDs).

1. pregnancy-induced hypertension (PIH). Mature pregnant clients are at increased risk for PIH and are more likely to require cesarean delivery. Also, their fetuses and neonates have a higher mortality and a higher incidence of trisomies. Iron deficiency anemia, cephalopelvic disproportion, and STDs may occur in any client regardless of age.

A client who's 32 weeks pregnant is hospitalized with preterm labor. After preterm labor is arrested, she's discharged with a prescription for oral ritodrine (Yutopar). Which instruction should the nurse provide during discharge teaching? 1. "Return to the clinic for a checkup in 6 weeks." 2. "Abstain from sexual intercourse unless you use a condom." 3. "You can return to your job as a hairdresser in 2 weeks." 4. "Take the medication as needed whenever contractions occur."

2. "Abstain from sexual intercourse unless you use a condom." A client who's predisposed to preterm labor should abstain from sexual intercourse unless she uses a condom because semen contains prostaglandins that stimulate uterine contractions. A client receiving ritodrine should return to the clinic in 1 to 2 weeks for a regular checkup and evaluation for preterm labor. Returning to work — especially to a job that involves much standing — is contraindicated immediately after preterm labor. Ritodrine must be taken regularly to prevent recurrence of preterm labor.

The nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask: 1. "Have you ever had osteomyelitis?" 2. "Do you have any cats at home?" 3. "Do you have any birds at home?" 4. "Have you recently had a rubeola vaccination?"

2. "Do you have any cats at home?" TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus — agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections.

A nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects the finding to be which of the following? 1. 22 cm 2. 30 cm 3. 36 cm 4. 40 cm

2. 30 cm During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus' age in weeks ± 2 cm . At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

After developing severe hydramnios, a primigravid client exhibits dyspnea, along with edema of the legs and vulva. Which procedure should the nurse expect her to undergo and why? 1. Artificial rupture of the membranes to reduce uterine pressure 2. Amniocentesis to temporarily relieve discomfort 3. I.V. oxytocin administration to induce labor 4. Cesarean delivery to prevent further fetal damage

2. Amniocentesis to temporarily relieve discomfort A client with hydramnios may undergo amniocentesis to relieve discomfort. However, because fluid production continues, the relief is temporary. Artificial rupture of the membranes, I.V. oxytocin administration, or cesarean delivery wouldn't relieve hydramnios.

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2. G = 2, T = 1, P = 0, A = 0, L = 1 Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks' gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks' gestation; included in parity [number of births] if past 20 weeks' gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

A client who's 30 weeks pregnant has a corrected atrial septal defect and minor functional limitations. Which pregnancy-related physiologic change places her at greatest risk for more severe cardiac problems? 1. Decreased heart rate 2. Increased plasma volume 3. Decreased cardiac output 4. Increased blood pressure

2. Increased plasma volume Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and boosting cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease 5 to 10 mm Hg, reaching its lowest point during the second half of the second trimester. During the third trimester, it gradually returns to first-trimester levels.

A client arrives at the clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was October 19, 2012. Using Nägele's rule, the nurse determines the estimated date of confinement is: 1. July 12, 2012 2. July 26, 2013 3. August 12, 2013 4. August 26, 2013

2. July 26, 2013 Accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Add 7 days to the first day of the last menstrual period, subtract 3 months, and then add 1 year to that date: first day of the last menstrual period, October 19, 2012; add 7 days, October 26, 2012; subtract 3 months, July 26, 2012; add 1 year, July 26, 2013.

The individual ultimately responsible for obtaining an informed consent from the client prior to a cesarean section is the: 1. Staff nurse. 2. Obstetrician. 3. Unit manager. 4. Admitting nurse.

2. Obstetrician. The person ultimately responsible for the procedure should provide the information necessary to obtain informed consent.

A nurse should explain which of the following to a pregnant client found to have a gynecoid pelvis? 1. That her type of pelvis has a narrow pubic arch 2. That her type of pelvis is the most favorable for labor and birth 3. That her type of pelvis is a wide pelvis, but has a short diameter 4. That she will need a cesarean section because this type of pelvis is not favorable for a normal labor and vaginal delivery

2. That her type of pelvis is the most favorable for labor and birth Rationale: A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating prescribed antibiotic therapy, the nurse should prepare the client for: 1. amniocentesis. 2. delivery. 3. sonography. 4. tocolytic therapy.

2. delivery. After rupture of the membranes in a client who has a fever or other signs or symptoms of infection, the fetus must be delivered promptly. Data obtained by amniocentesis or sonography wouldn't change the decision to deliver the fetus. Tocolytic drugs are used to arrest preterm labor.

A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited but is concerned because she herself isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by: 1. referring her to counseling. 2. reassuring her such feelings are normal in the beginning of pregnancy. 3. exploring her feelings. 4. recommending she talk her feelings over with her husband.

2. reassuring her such feelings are normal in the beginning of pregnancy. Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but the husband also needs to be reassured that these feelings are normal at this time.

A nursing student is preparing a prenatal class on the process of fetal circulation. The nursing instructor asks the student specifically to describe the process through the umbilical cord . Which of the following statements from the student is correct? 1. "The one artery carries freshly oxygenated blood and nutrient-rich blood back from the placenta to the fetus." 2. "The two arteries carry freshly oxygenated blood and nutrient-rich blood back from the placenta to the fetus." 3. "The two arteries in the umbilical cord carry deoxygenated blood and waste products away from the fetus to the placenta." 4. "The two veins in the umbilical cord carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."

3. "The two arteries in the umbilical cord carry deoxygenated blood and waste products away from the fetus to the placenta." Rationale: Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries. When oxygenated, the blood is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus.

A client, 8 weeks pregnant, has a history of lactose intolerance. To prevent a nutritional deficiency as a result of lactose intolerance, the nurse teaches her about lactase replacement. Which teaching point is appropriate? 1. Add lactase replacement drops to milk immediately before drinking it. 2. Ask the physician for a lactase prescription that allows unlimited refills. 3. Add lactase replacement drops to milk at least 24 hours before drinking it. 4. Warm milk to room temperature before adding lactase replacement tablets.

3. Add lactase replacement drops to milk at least 24 hours before drinking it. A client with lactose intolerance must take lactase replacement drops or tablets whenever milk or a milk product is consumed. The drops must be added to a carton of milk at least 24 hours before the milk is consumed to ensure proper action. Lactase replacement drops and tablets are available without a prescription. Milk need not be warmed to room temperature before adding lactase replacement products.

When should a client who's Rh(D)-negative and D-negative and who hasn't already formed Rh antibodies receive Rho(D) immune globulin (RhoGam) to prevent isoimmunization? 1. At about 28 weeks' gestation only 2. Within 72 hours after delivery only 3. At about 28 weeks' gestation and again within 72 hours after delivery 4. At about 32 weeks' gestation and again within 24 hours after delivery

3. At about 28 weeks' gestation and again within 72 hours after delivery A client who's Rh(D)-negative and D-negative and who hasn't already formed Rh antibodies should receive Rho(D) immune globulin at about 28 weeks' gestation and again within 72 hours after delivery. Giving Rho(D) immune globulin only at 28 weeks' gestation wouldn't prevent isoimmunization from occurring after placental separation, when fetal blood enters the maternal circulation. Giving Rho(D) immune globulin only within 72 hours after delivery wouldn't prevent isoimmunization caused by passage of fetal blood into the maternal circulation during gestation. Giving Rho(D) immune globulin at 32 weeks' gestation would be too late to prevent isoimmunization during pregnancy because Rh antibodies already have formed by then. Giving Rho(D) immune globulin within 24 hours after delivery would be too soon because maternal sensitization occurs in approximately 72 hours.

A nursing student is assigned to care for a client in labor. A nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The nursing instructor determines that the student understands fetal circulation if the student states that the ductus venosus: 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava

3. Connects the umbilical vein to the inferior vena cava Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. Options 1, 2, and 4 are incorrect. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

A client, 18 weeks pregnant, arrives in the emergency department. A short time later, her placental membranes rupture spontaneously. The physician prescribes carboprost (Hemabate), 250 mcg/ml I.M., and asks about her obstetric history. Why is this history important? 1. Increased gravidity slows carboprost's onset of action. 2. Increased parity slows carboprost's onset of action. 3. Increased gravidity or parity speeds carboprost's onset of action. 4. Carboprost's onset of action is faster if gravidity is greater than parity.

3. Increased gravidity or parity speeds carboprost's onset of action. Carboprost's peak onset of action occurs about 16 hours after I.M. injection. However, onset is faster with increased gravidity (number of pregnancies) or parity (number of live births) and is slower with increased fetal gestational age.

A pregnant client is seen in a health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that she is experiencing Braxton Hicks contractions . Based on this finding, which nursing action is appropriate? 1. Contact the physician. 2. Instruct the client to maintain bedrest for the remainder of the pregnancy. 3. Inform the client that these contractions are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

3. Inform the client that these contractions are common and may occur throughout the pregnancy. Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 2, and 4 are unnecessary and inappropriate actions.

A nurse explains some of the purposes of the placenta to a client during a prenatal visit. The nurse determines that the client understands some of these purposes when the client states that the placenta: 1. Cushions and protects the baby. 2. Maintains the temperature of the baby. 3. Is the way the baby gets food and oxygen. 4. Prevents all antibodies and viruses from passing to the baby.

3. Is the way the baby gets food and oxygen. Rationale: The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, drugs, antibodies, and viruses can pass through the placenta.

When performing a vaginal examination on a pregnant client, the nurse determines that the biparietal diameter of the fetal head has reached the pelvic inlet. Which statement best describes the position of the fetus at this time? 1. It's at the ischial spines. 2. It's at first station. 3. It's engaged. 4. It's floating.

3. It's engaged. The largest part of the fetus's head, the presenting part, is marked by the biparietal diameter. The largest part of the head is accommodated by the largest part of the passage — the pelvic inlet. Engagement refers to entry of the fetus's head or presenting part into the superior pelvic strait, which is marked by the pelvic inlet. When the fetus's head is at the level of the ischial spines, it's at the pelvic outlet. The ischial spines are designated as zero station. A floating fetus hasn't yet entered the pelvic inlet.

A client who's 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client isn't in labor. Which nursing intervention should the nurse perform? 1. Allow the client to ambulate with assistance. 2. Perform a vaginal examination to check for cervical dilation. 3. Monitor the amount of vaginal blood loss. 4. Notify the physician for a fetal heart rate of 130 beats/minute.

3. Monitor the amount of vaginal blood loss. Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute.

A client's prenatal record shows that she's a gravida 2, para 0111. From this information, the nurse knows that she has been pregnant twice. What else does this information reveal about her obstetric history? 1. One pregnancy resulted in a term neonate who's living and one resulted in a preterm neonate who's living. 2. One pregnancy resulted in an abortion and one resulted in a term neonate who's living. 3. One pregnancy resulted in an abortion and one resulted in a preterm neonate who's living. 4. One pregnancy resulted in a term neonate who's living and one resulted in a preterm neonate who died.

3. One pregnancy resulted in an abortion and one resulted in a preterm neonate who's living. A client's previous pregnancies are documented according to her number of Term infants, number of Preterm infants, number of Abortions, and number of Living children (or TPAL). In the TPAL method, the first element (0, in this case) indicates the number of term neonates. The second element (1) indicates the number of preterm neonates delivered. The third element (1) represents the number of spontaneous or therapeutic abortions. The fourth element (1) represents the number of children alive. One pregnancy that resulted in a term neonate who's living and one that resulted in a preterm neonate who's living would be documented as para 1102. One pregnancy that resulted in an abortion and one that resulted in a term neonate who's living would be documented as para 1011. One pregnancy that resulted in a term neonate who's living and one that resulted in a preterm neonate who died would be documented as para 1101.

A nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, the nurse responds that the reason for this is that it: 1. Promotes the fertilized ovum's chances of survival 2. Promotes the fertilized ovum's exposure to estrogen and progesterone 3. Promotes the fertilized ovum's normal implantation in the top portion of the uterus 4. Promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone

3. Promotes the fertilized ovum's normal implantation in the top portion of the uterus Rationale: The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus . Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days.

A pregnant teenager admitted with premature uterine contractions was successfully treated with I.V. fluids. She is eager to return to high school to take a math test. The nurse's discharge examination reveals vaginal blood pooling under the teen's buttocks that's painless to the client. Which discharge planning step should the nurse take? 1. Encourage developmental growth by wishing the client luck on her math test. 2. Teach the client to measure the amount of bleeding and when to notify the physician. 3. Stop the discharge process and notify the physician immediately. 4. Reassure the client that she doesn't need to be concerned about the bleeding because she had I.V. fluids.

3. Stop the discharge process and notify the physician immediately. Vaginal bleeding that's painless suggests placenta previa, a life-threatening condition. The client diagnosed with placental previa who is actively bleeding shouldn't be discharged. Pooling of blood indicates a significant amount of bleeding. The client's developmental and emotional growth is important but it isn't life threatening. Client education should focus on the new onset of painless bleeding. The client should be taught to monitor bleeding after delivery, not before. I.V. fluids increase fluid volume but don't stop vaginal bleeding.

A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? 1. The fetus should be delivered within 24 hours. 2. The client should repeat the test in 24 hours. 3. The fetus isn't in distress at this time. 4. The client should repeat the test in 1 week.

3. The fetus isn't in distress at this time. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits.

A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her? 1. This symptom is abnormal during the third trimester and may indicate a urinary tract infection. 2. This symptom is a normal variation and is easily managed by limiting fluid intake. 3. This symptom is normal and results from the fetus exerting pressure on the bladder. 4. This symptom is abnormal and should subside after the presenting part of the fetus is engaged.

3. This symptom is normal and results from the fetus exerting pressure on the bladder. During the first trimester, hormonal changes and uterine pressure on the bladder cause urinary frequency and urgency. During the second trimester, when the uterus rises out of the pelvis, urinary symptoms abate. However, as term approaches, pressure on the bladder by the presenting part of the fetus again causes urinary frequency and urgency. Urinary frequency isn't abnormal unless accompanied by other urinary symptoms, such as burning and pain. Fluids shouldn't be limited during pregnancy. Urinary frequency doesn't subside after the presenting part is engaged. Instead, the presenting part exerts pressure on the bladder.

A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy? 1. Signs and symptoms of labor 2. Quickening and fetal movements 3. Warning signs of complications 4. False labor and true labor

3. Warning signs of complications In early childbirth education classes, instruction on the physiologic aspects of pregnancy may include warning signs of complications, the anatomy and physiology of pregnancy, nutrition, and fetal development. Signs and symptoms of labor, quickening and fetal movements, and false and true labor are discussed in later classes.

A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from: 1. a neurologic disorder. 2. inadequate nutrition. 3. an unknown cause. 4. hemolysis of fetal red blood cells (RBCs).

3. an unknown cause. The cause of hyperemesis gravidarum isn't known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs.

A client who's 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse anticipates that at 16 weeks' gestation, the client's fetus will: 1. be able to suck and swallow. 2. open the eyes. 3. have audible heart sounds. 4. have open nostrils.

3. have audible heart sounds. Fetal heart tones are usually audible with a fetoscope between 16 and 20 weeks' gestation. The fetus can suck and swallow at about 20 weeks' gestation. The eyes are open at approximately 28 weeks' gestation. The nostrils are open at about 21 to 28 weeks' gestation.

A client has come to the clinic for her first prenatal visit. The nurse should include which statement about using drugs safely during pregnancy in her teaching? 1. "During the first 3 months, avoid all medications except ones prescribed by your caregiver." 2. "Medications that are available over the counter are safe for you to use, even early on." 3. "All medications are safe after you've reached the 5th month of pregnancy." 4. "Consult with your health care provider before taking any medications."

4. "Consult with your health care provider before taking any medications." Because all medications can be potentially harmful to the growing fetus, telling the client to consult with her health care provider before taking any medications is the best teaching. The client needs to understand that any medication taken at any time during pregnancy can be teratogenic.

A pregnant client asks how she can best prepare her 3-year-old son for the upcoming birth of a sibling. The nurse should make which suggestion? 1. "Tell your son about the childbirth about 1 month before your due date." 2. "Reassure your son that nothing is going to change." 3. "Reprimand your son if he displays immature behavior." 4. "Involve your son in planning and preparing for a sibling."

4. "Involve your son in planning and preparing for a sibling." Being involved in the pregnancy helps reinforce a child's position in the family and minimizes feelings of neglect and abandonment. Telling the child about the childbirth only 1 month before the due date wouldn't allow enough time to prepare him for the sibling and would prevent him from conceptualizing the passage of time. Reassuring him that nothing will change would be misleading; instead, the parents should discuss which aspects of family life will be changed by the upcoming birth and which will remain the same. Parents should reward mature behavior and ignore immature behavior.

A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe level of alcohol intake for this client? 1. "The client consumes no more than 2 oz of alcohol daily." 2. "The client consumes no more than 4 oz of alcohol daily." 3. "The client consumes 2 to 6 oz of alcohol daily, depending on body weight." 4. "The client consumes no alcohol."

4. "The client consumes no alcohol." A safe level of alcohol intake during pregnancy hasn't been established. Therefore, authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth retardation, short palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may predispose her to complications in early pregnancy.

A post-abortion 16-year-old female asks the nurse questions concerning birth control options prior to discharge. Which of the following legal or ethical issues are involved when this nurse answers questions concerning birth control for this client? 1. Moral dilemma 2. Mature minor 3. Advance directives 4. Emancipated minor

4. Emancipated minor An advance directive is a method to inform clients of their rights, including a preference for treatment options. A moral dilemma is a conflict of social values and ethical principles that support different courses of action. Mature minors are usually between the ages of 14 and 15. This client was 16, had an abortion, and was seeking birth control. Adolescents between the ages of 16 and 18 who seek birth control can provide informed consent for the treatment as an emancipated minor.

A nurse who uses current research, statistical data, and quality measurements as a guide for nursing care is providing care that is: 1.Based on personal opinion. 2. Directed by habit. 3. Derived from memory. 4. Evidence-based.

4. Evidence-based. Evidence-based practice is nursing care in which all interventions are supported by current, valid research. Evidence-based practice allows the nurse to transform current research findings into clinical practice. The nurse considers all forms of evidence, such as statistical data, quality measurements, risk-management measures, and information from support services, to deliver care that is supported by solid evidence. The other three options do not involve research, statistical data, or quality measurements.

When evaluating a pregnant client's fundal height, the nurse should measure in which way? 1. Across the abdomen laterally 2. From the symphysis pubis notch to the umbilicus 3. With a pelvimeter designed to measure fundal height 4. From the symphysis pubis notch to the highest level of the fundus

4. From the symphysis pubis notch to the highest level of the fundus To measure fundal height, the nurse should stretch a measuring tape over the client's enlarged abdomen and measure from the symphysis pubis notch to the highest level of the fundus, determined by palpation. Measuring across the abdomen and measuring from the symphysis pubis to the umbilicus are incorrect procedures for measuring fundal height. A pelvimeter is used to evaluate the size of the maternal pelvis for delivery, not fundal height.

A nurse in a prenatal clinic is assessing a 28-year-old who's 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia? 1. Glycosuria, hypertension, seizures 2. Hematuria, blurry vision, reduced urine output 3. Burning on urination, hypotension, abdominal pain 4. Hypertension, edema, proteinuria

4. Hypertension, edema, proteinuria The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't typically found in women with preeclampsia.

A nurse-midwife is assessing a pregnant client for the presence of ballottement. To make this determination, the nurse-midwife does which of the following? 1. Auscultates for fetal heart sounds 2. Assesses the cervix for compressibility 3. Palpates the abdomen for fetal movement 4. Initiates a gentle upward tap on the cervix

4. Initiates a gentle upward tap on the cervix Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound . In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger. Options 1, 2, and 3 are not assessment techniques to check for ballottement. Option 2 is related to Hegar's sign. Options 1 and 3 are a part of fetal assessment.

Assessment of a client progressing through labor reveals the following findings. Order the findings in the most likely sequence in which they would have occurred. 1. Uncontrollable urge to push 2. Cervical dilation of 7 cm 3. 100% cervical effacement 4. Strong Braxton-Hicks contractions 5. Mild contractions lasting 20 to 40 seconds

4. Strong Braxton-Hicks contractions 5. Mild contractions lasting 20 to 40 seconds 2. Cervical dilation of 7 cm 3. 100% cervical effacement 1. Uncontrollable urge to push Strong Braxton-Hicks contractions typically occur before the onset of true labor and are considered a preliminary sign of labor. During the latent phase of the first stage of labor, contractions are mild, lasting approximately 20 to 40 seconds. As the client progresses through labor, contractions increase in intensity and duration. In addition, cervical dilation occurs. Cervical dilation of 7 cm indicates that the client has entered the active phase of the first stage of labor. Together with cervical dilation, cervical effacement occurs. Effacement of 100% characterizes the transition phase of the first stage of labor. Progression into the second stage of labor is noted by the client's uncontrollable urge to push.

An 18-year-old pregnant woman tells the nurse that she's concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn't provide insurance. The nurse should recognize that she: 1. may not take care of herself. 2. may not be fit to take care of a child. 3. needs to take up a second job. 4. should be referred to community resources available for pregnant women.

4. should be referred to community resources available for pregnant women. The client needs to know that resources are available to her, and the nurse should help her to find those resources. Health care can be costly but it doesn't necessarily mean that the client has no interest in caring for herself or her child. Taking up a second job doesn't necessarily solve this situation.

Nullipara

a woman who has not had a birth at more than 20 weeks of gestation

Incomplete abortion

Loss of some of the products of conception occurs, with part of the products retained (most often placenta is retained)

LEOPOLD'S MANEUVERS

Methods of palpation to determine presentation and position of the fetus and aid in location of fetal heart sounds If the head is in the fundus, a hard, round, movable object is felt. The buttocks feel soft and have an irregular shape and are more difficult to move. The fetus' back, which is a smooth, hard surface, should be felt on one side of the abdomen. Irregular knobs and lumps, which may be the hands, feet, elbows, and knees, are felt on the opposite side of the abdomen.

Nonreactive Nonstress Test (Abnormal)

No accelerations or accelerations of less than 15 beats/ min or lasting less than 15 seconds in duration occur during a 40-minute observation.

When caring for a client who's a primigravida, the nurse would expect that the second stage would normally last how long? 1. Approximately 2 hours 2. Less than 1 hour 3. 4 hours 4. 3 hours

1. Approximately 2 hours The average length of time a primigravida needs to push is approximately 2 hours. Longer than that might mean the client is experiencing an arrest in descent. Few primigravidas have a second stage of labor shorter than 1 hour.

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? 1. Duration, frequency, and intensity 2. Dilatation, duration, and frequency 3. Frequency, duration, maternal position 4. Dilatation, effacement, position

1. Duration, frequency, and intensity The nurse should document the duration, frequency, and intensity of uterine contractions. Dilatation refers to the number of centimeters the cervix is dilated; it doesn't describe uterine contractions. Maternal position doesn't help describe uterine contractions. Dilatation and effacement both refer to the condition of the cervix, not uterine contractions.

Normal lochial findings in the first 24 hours following delivery include: 1. bright red blood. 2. large clots or tissue fragments. 3. a foul odor. 4. the complete absence of lochia.

1. bright red blood. Bright red blood is a normal lochial finding in the first 24 hours after delivery. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.

The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation? 1. Chills 2. Scant lochia rubra 3. Thirst and fatigue 4. Temperature of 100.2° F (37.9° C)

2. Scant lochia rubra During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4° F (38° C) also are common at 24 hours postpartum.

A client with human immunodeficiency virus (HIV) infection delivers a neonate. When assessing the neonate, the nurse is most likely to detect: 1. skin vesicles. 2. limb dysmorphism. 3. conjunctivitis. 4. hepatosplenomegaly.

4. hepatosplenomegaly. A neonate with HIV infection typically has hepatosplenomegaly, a distinctive facial dysmorphism, interstitial pneumonia, recurrent infections, behavioral deviations, and neurologic abnormalities. The other options aren't typical findings in neonates with HIV infection.

Plus station

Below ischial spine

LMA

Left mentoanterior

Ankle edema in pregnancy

Usually occurs in the second and the third trimesters Results from vasodilation, venous stasis, and increased venous pressure below the uterus

During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response? 1. "8 days after conception" 2. "When the woman misses a menstrual period" 3. "2 to 3 weeks after fertilization" 4. "As soon as hormone levels decline"

1. "8 days after conception" Based on human chorionic gonadotropin (hCG) levels in the blood and urine, pregnancy can be diagnosed as early as 8 days after conception, when the syncytiotrophoblast produces hCG. Sensitive and specific pregnancy tests can detect hCG in the blood and urine even before the first missed menstrual period. A missed period may also be related to other factors, such as poor nutrition, strenuous athletic activity, and certain drugs. Levels of hCG rise rapidly until about the 20th week of gestation. By the 20th week, they decline gradually and stay low for the remainder of gestation. Other hormones, such as human placental lactogen, estrogen, and progesterone, increase during pregnancy.

A client is expecting her second child in 6 months. During the psychosocial assessment, she says, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response? 1. "Each pregnancy has a unique psychosocial meaning." 2. "The facility requires these answers of all pregnant clients." 3. "A second pregnancy may require more psychosocial adjustment." 4. "A client can develop couvade with any pregnancy."

1. "Each pregnancy has a unique psychosocial meaning." With each pregnancy, a woman explores a new aspect of the mother role and must reformulate her self-image as a pregnant woman and a mother. The other options don't address the client's feelings. No evidence suggests that a second pregnancy requires more adjustment. Couvade symptoms occur in the father, not the mother.

At 28 weeks' gestation, a client is admitted to the labor and delivery area in preterm labor. An I.V. infusion of ritodrine (Yutopar) is started. Which client outcome reflects the nurse's awareness of an adverse effect of ritodrine? 1. "The client remains free from tachycardia." 2. "The client remains free from polyuria." 3. "The client remains free from hypertension." 4. "The client remains free from hyporeflexia."

1. "The client remains free from tachycardia." Ritodrine and other beta-adrenergic agonists may cause tachycardia, hypotension, bronchial dilation, increased plasma volume, increased cardiac output, arrhythmias, myocardial ischemia, reduced urine output, restlessness, headache, nausea, and vomiting. These drugs aren't associated with polyuria, hypertension, or hyporeflexia.

A nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately."

1. "We want to attend a support group." A support group can help the parents work through their pain by nonjudgmental sharing of feelings. Option 1 identifies a statement that would indicate positive, normal grieving. Although the other options may indicate reactions of the client and significant other , they are not specifically a part of the normal grieving process.

The nurse is about to give a full-term neonate his first bath. How should the nurse proceed? 1. Bathe the neonate only after his vital signs have stabilized. 2. Clean the neonate with medicated soap. 3. Scrub the neonate's skin to remove the vernix caseosa. 4. Wash the neonate from feet to head.

1. Bathe the neonate only after his vital signs have stabilized. To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions, through which microorganisms can enter. The nurse should wash the neonate from head to feet.

A nurse is demonstrating cord care to a mother of a neonate. Which actions would the nurse teach the mother to perform? 1. Keep the diaper below the cord. 2. Tug gently on the cord as it begins to dry. 3. Apply antibiotic ointment to the cord twice daily. 4. Only sponge-bathe the infant until the cord falls off. 5. Clean the length of the cord with alcohol several times daily. 6. Wash the cord with mild soap and water.

1. Keep the diaper below the cord. 4. Only sponge-bathe the infant until the cord falls off. 5. Clean the length of the cord with alcohol several times daily. The diaper should be positioned below the cord to allow it to air dry and to prevent urine from getting on the cord. Soap and water shouldn't be used as a part of cord care. The nurse should instruct the parents to sponge bathe the infant until the cord falls off. The entire cord should be cleaned with alcohol, using a cotton swab or another appropriate method. Parents should also be instructed to never pull on the cord, but to allow it to fall off naturally. Antibiotic ointments are contraindicated unless there are signs of infection.

Pregnancy and GI system

1. Nausea and vomiting may occur as a result of the secretion of human chorionic gonadotropin; it subsides by the third month. 2. Poor appetite may occur because of decreased gastric motility. 3. Alterations in taste and smell may occur. 4. Constipation may occur because of an increase in progesterone production or pressure of the uterus resulting in decreased gastrointestinal motility. 5. Flatulence and heartburn may occur because of decreased gastrointestinal motility and slowed emptying of the stomach caused by an increase in progesterone production. 6. Hemorrhoids may occur because of increased venous pressure. 7. Gum tissue may become swollen and easily bleed because of increasing levels of estrogen. 8. Ptyalism (excessive secretion of saliva) may occur because of increasing levels of estrogen.

Skin changes during pregnancy

1. Some changes occur because the levels of melanocyte-stimulating hormone increase as a result of an increase in estrogen and progesterone levels; these changes include the following: a. Increased pigmentation b. Dark streak down the midline of the abdomen (linea nigra) c. Chloasma (mask of pregnancy)— a blotchy brownish hyperpigmentation, over the forehead, cheeks, and nose d. Reddish purple stretch marks (striae) on the abdomen, breasts, thighs, and upper arms 2. Vascular spider nevi may occur on the neck, chest, face, arms, and legs. 3. Rate of hair growth may increase.

Assessment findings for chorioamnionitis

1. Uterine tenderness and contractions 2. Elevated temperature 3. Maternal or fetal tachycardia 4. Foul odor to amniotic fluid 5. Leukocytosis

The nurse is teaching a client how to use a diaphragm. Which instruction should the nurse provide? 1. "Insert the diaphragm 4 hours before intercourse." 2. "Leave the diaphragm in place for at least 6 hours after intercourse." 3. "Remove the diaphragm immediately after intercourse." 4. "You may use the diaphragm without spermicidal jelly or cream."

2. "Leave the diaphragm in place for at least 6 hours after intercourse." The diaphragm acts as a reservoir for spermicidal jelly or cream and must be left in place for at least 6 hours after intercourse to ensure spermicidal action. Inserting the diaphragm 4 hours before intercourse or removing it immediately afterward doesn't ensure spermicidal effectiveness. A diaphragm must be used with spermicidal jelly or cream.

During her fourth clinic visit, a client who's 5 months pregnant tells the nurse she was exposed to rubella during the past week and asks whether she can be immunized now. How should the nurse respond? 1. "Yes but immunization against rubella requires a physician's order." 2. "No because the live viral vaccine is contraindicated during pregnancy." 3. "Yes and you should consider pregnancy termination because rubella has teratogenic effects." 4. "No because the vaccine can be given only during the first trimester."

2. "No because the live viral vaccine is contraindicated during pregnancy." Rubella immunization is contraindicated during pregnancy because the vaccine contains live virus, which can have teratogenic effects on the fetus. Needing a physician's order isn't a valid reason for withholding an immunization. Recommending pregnancy termination forces the nurse's viewpoint on the client rather than allowing the client to decide for herself. Exposure to rubella virus may have teratogenic effects if the client is exposed during the first trimester.

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? 1. "Yes, it produces no adverse effects." 2. "No, it can initiate premature uterine contractions." 3. "No, it can promote sodium retention." 4. "No, it can lead to increased absorption of fat-soluble vitamins."

2. "No, it can initiate premature uterine contractions." Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it doesn't promote sodium retention. Castor oil isn't known to increase absorption of fat-soluble vitamins, although laxatives can decrease absorption if intestinal motility is increased.

A client scheduled for a vasectomy asks the nurse how soon after the procedure he can have sexual intercourse without using an alternative birth control method. How should the nurse respond? 1. "You can safely have unprotected intercourse after 6 to 10 ejaculations." 2. "You can safely have unprotected intercourse when your sperm count indicates sterilization." 3. "You can safely have unprotected intercourse immediately after the procedure." 4. "You can safely have unprotected intercourse as soon as discomfort from the procedure disappears."

2. "You can safely have unprotected intercourse when your sperm count indicates sterilization." After a vasectomy, sterilization isn't ensured until the client's sperm count measures zero. This usually requires 6 to 36 ejaculations. Having intercourse immediately after the procedure or as soon as discomfort disappears may lead to pregnancy.

A client in the first trimester of pregnancy comes to the facility for a routine prenatal visit. She tells the nurse she doesn't know whether she's ready to have a baby, even though this was a planned pregnancy. Which response should the nurse offer? 1. "You may want to discuss these concerns with a social worker." 2. "You're feeling ambivalent, which is normal during the first trimester." 3. "You need to share these feelings with your partner." 4. "You may want to consider having an abortion."

2. "You're feeling ambivalent, which is normal during the first trimester." The first trimester is known as the trimester of ambivalence because the client or the couple may experience mixed feelings. During this trimester, resolution of ambivalence is the family's key psychosocial task. Discussing these feelings with a social worker or the client's partner would be inappropriate at this time. (However, if further assessment reveals there is a problem, referral to a social worker and discussion with the partner may be appropriate.) Suggesting that the client consider having an abortion is a leading statement and would be inappropriate.

A nurse in the neonatal nursery is preparing to perform phenylketonuria (PKU) testing. Which baby is ready for the nurse to test? 1. A 3-day-old baby who has been fed I.V. since birth 2. A 2-day-old baby who has been breast-fed 3. A 1-day-old baby receiving formula 4. A breast-fed baby being discharged within 24 hours of birth

2. A 2-day-old baby who has been breast-fed To test for PKU, a baby must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A baby who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A baby who's discharged within 24 hours of delivery will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours.

After delivering a neonate, a client delivers the placenta. At this time, where does the nurse expect to palpate the uterine fundus? 1. At the midline, 0.4" to 0.8" (1 to 2 cm) above the umbilicus 2. At the midline, 0.4" to 0.8" (1 to 2 cm) below the umbilicus 3. Left of the midline, 0.8" to 1" (2 to 3 cm) above the umbilicus 4. Left of the midline, 0.8" to 1" (2 to 3 cm) below the umbilicus

2. At the midline, 0.4" to 0.8" (1 to 2 cm) below the umbilicus After delivery of the placenta, the fundus is normally firmly contracted at the midline, 0.4" to 0.8" (1 to 2 cm) below the umbilicus.

Which of the following is the primary reason for putting breast-feeding neonates to the breast immediately after delivery? 1. Neonates are hungry and need to eat. 2. Breast-feeding neonates immediately after birth establishes a learned response. 3. It's a good opportunity to teach the mother about breast-feeding. 4. It fosters maternal attachment.

2. Breast-feeding neonates immediately after birth establishes a learned response. Immediately following birth, most neonates are quietly alert and are ready to nurse. Therefore, this is an ideal time to begin breast-feeding. Also, as one of the first postbirth experiences, the neonate is able to develop a learned response for feeding. The other answers are acceptable, but they don't consider the importance of developing responses as part of breast-feeding success.

A postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse provides which appropriate instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently.

2. Continue to breast-feed every 2 to 4 hours. Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process . Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate? 1. Administering aspirin as ordered 2. Encouraging increased fluid intake 3. Reassessing vital signs every 15 minutes 4. Requesting an antibiotic order

2. Encouraging increased fluid intake During the 1st postpartum day, mild dehydration commonly causes a slight temperature elevation; the nurse should encourage fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may increase the risk of hemorrhage. Reassessing vital signs in 4 hours is sufficient to assess the effectiveness of hydration measures. The nurse should request an antibiotic order if the client's oral temperature exceeds 100.4° F (38° C), which suggests infection.

A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action? 1. Make an appointment because the client needs to be evaluated. 2. Explain that these are expected problems for the latter stages of pregnancy. 3. Arrange for the client to be admitted to the birth center for delivery. 4. Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume.

2. Explain that these are expected problems for the latter stages of pregnancy. The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. These signs aren't indicative of heart failure. The client doesn't need to be seen or admitted for delivery.

The nurse obtains the antepartum history of a client who's 6 weeks pregnant. Which finding should the nurse discuss with the client first? 1. Her participation in low-impact aerobics three times per week 2. Her consumption of six to eight cans of beer on weekends 3. Her consumption of four to six small meals daily 4. Her practice of taking a multivitamin supplement daily

2. Her consumption of six to eight cans of beer on weekends Consuming any amount or type of alcohol isn't recommended during pregnancy because it increases the risk of fetal alcohol syndrome or fetal alcohol effect. If the client is accustomed to moderate exercise, she may continue to engage in low-impact aerobics during pregnancy. Eating frequent, small meals helps maintain the client's energy level by keeping the blood glucose level relatively constant. Taking a multivitamin supplement daily and eating a balanced diet are recommended during pregnancy.

Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? 1. Applying cold to limit edema during the first 12 to 24 hours 2. Instructing the client to use two or more peripads to cushion the area 3. Instructing the client on the use of sitz baths if ordered 4. Instructing the client about the importance of perineal (Kegel) exercises

2. Instructing the client to use two or more peripads to cushion the area Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.

Several minutes after a vaginal delivery, nursing assessment reveals blood gushing from the client's vagina, umbilical cord lengthening, and a globular-shaped uterus. The nurse should suspect which condition? 1. Cervical or vaginal laceration 2. Placental separation 3. Postpartum hemorrhage 4. Uterine involution

2. Placental separation Placental separation is characterized by a sudden gush or trickle of blood from the vagina, further protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. With cervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartum hemorrhage, usually caused by uterine atony, the uterus isn't globular. Uterine involution can't begin until the placenta has been delivered.

During labor, a client greatly relies on her husband for support. They previously attended childbirth education classes, and now he's working with her on comfort measures. Which nursing diagnosis would be appropriate for this couple? 1. Compromised family coping related to labor 2. Readiness for enhanced family coping related to participation in pregnancy and delivery 3. Powerlessness related to pain 4. Ineffective role performance related to involvement with the pregnancy

2. Readiness for enhanced family coping related to participation in pregnancy and delivery The client and her husband are working together for a common goal. He's offering support, and they're sharing the experience of childbirth, making Readiness for enhanced family coping related to participation in pregnancy and delivery an appropriate nursing diagnosis. The other options suggest that the couple have a problem that isn't indicated in the question.

Jason Walker, a 22-year-old patient is concerned that a lack of testosterone will interfere with his sperm production and ability to father children. You respond with which of the following statements? 1. Testosterone can be provided as a supplement, which will improve his ability to father children. 2. Several hormones work together to stimulate sperm formation and mature sperm for fertilization. 3. Testosterone primarily is responsible for male sex characteristics and libido, rather than sperm production. 4. The lack of testosterone will not interfere with sperm production and fertility.

2. Several hormones work together to stimulate sperm formation and mature sperm for fertilization. Follicle stimulating hormone, estrogen, and testosterone are all responsible for sperm formation and sperm maturation. Although testosterone supplements are available, other hormones may be responsible for fertility issues. Testosterone is responsible for the development of male sex characteristics and is also responsible for the growth and division of cells that mature sperm. The lack of testosterone could be one contributing factor to lack of mature sperm based on its function, which may interfere with fertility.

The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction? 1. Deep breathing 2. Shallow chest breathing 3. Deep, cleansing breaths 4. Chest panting

2. Shallow chest breathing Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated.

The nurse is conducting an assessment of a neonate born 3 hours ago. Which finding would make the nurse suspect a congenital hip dislocation? 1. Limited adduction of the affected leg 2. Unequal gluteal folds 3. Lengthening of the limb on the affected side 4. Crepitus of the affected hip on movement

2. Unequal gluteal folds Unequal gluteal folds are a sign of congenital hip dislocation. Other signs include unequal thighs, limited adduction of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip isn't felt, but an audible click may be heard when the hip on the affected side is adducted.

What is a common adverse effect of phototherapy? 1. Kernicterus 2. Watery stools 3. Positive Coombs' test 4. Polyuria

2. Watery stools Phototherapy involves exposing an infant's bare skin to intense fluorescent light in the treatment of hyperbilirubinemia and jaundice. Watery stools result from excretion of bilirubin. Kernicterus is a complication of jaundice — not phototherapy. Coombs' test is performed to determine the cause of jaundice and is unrelated to phototherapy. Polyuria isn't a result of phototherapy.

A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar score, the nurse assesses the neonate's: 1. temperature. 2. respiration. 3. blood pressure. 4. weight.

2. respiration. The Apgar score is determined by the neonate's heart rate, respiration, muscle tone, reflex irritability, and color. Temperature, blood pressure, and weight don't count toward the Apgar score.

The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client would indicate an understanding of the nurse's teaching? 1. "I'll need to lie perfectly still." 2. "You won't need to come in and check on me while I'm wearing this monitor." 3. "I can lie in any comfortable position, but I should stay off my back." 4. "I know that the external monitor increases my risk of a uterine infection."

3. "I can lie in any comfortable position, but I should stay off my back." A woman with an external monitor should lie in the position that is most comfortable to her, although the supine position should be discouraged. A woman should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who's wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.

During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates an accurate understanding of the nurse's instructions? 1. "I'll decrease my intake of green, leafy vegetables." 2. "I'll limit fluid intake to four 8-oz glasses." 3. "I'll increase my intake of unrefined grains." 4. "I'll take iron supplements regularly."

3. "I'll increase my intake of unrefined grains." During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates an accurate understanding of the nurse's instructions?

While bottle-feeding her neonate, a postpartum client asks the nurse when she can expect her menstrual period to return. How should the nurse respond? 1. "In 1 to 2 weeks" 2. "In 3 to 4 weeks" 3. "In 7 to 9 weeks" 4. "In 10 to 12 weeks"

3. "In 7 to 9 weeks" In nonlactating clients, menstruation typically resumes 7 to 9 weeks after delivery. The average time before return of ovulation is about 10 weeks after delivery.

A client with type 1 diabetes mellitus has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide? 1. "Insulin requirements don't change during pregnancy. Continue your current regimen." 2. "Insulin requirements usually decrease during the last two trimesters." 3. "Insulin requirements usually decrease during the first trimester." 4. "Insulin requirements increase greatly during labor."

3. "Insulin requirements usually decrease during the first trimester." Maternal insulin requirements usually decrease during the first trimester from rapid fetal growth and maternal metabolic changes, necessitating adjustment of the insulin dosage. Maternal insulin requirements fluctuate throughout pregnancy; after decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish from extreme maternal energy expenditure.

A client in the fourth stage of labor asks to use the bathroom for the first time since delivery. The client has oxytocin (Pitocin) infusing. Which response by the nurse is best? 1. "You'll have to wait until the vaginal bleeding stops." 2. "You'll have to wait until the oxytocin is infused." 3. "You may use the bathroom with my assistance." 4. "You may get up to the bathroom whenever you need to."

3. "You may use the bathroom with my assistance." The nurse should tell the client that she may use the bathroom with the nurse's assistance. The nurse should assist the client for the client's first trip to the bathroom after delivery. It isn't uncommon for a client to faint after delivery. Telling the client she must wait until her vaginal bleeding stops is inappropriate; vaginal bleeding continues for about 6 weeks after delivery. The nurse shouldn't tell the client she can get up whenever she needs to use the bathroom; doing so places the client at risk for injury.

After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at -1 station. Based on these findings, the nurse-midwife knows that the fetal presenting part is: 1. 1 cm below the ischial spines. 2. directly in line with the ischial spines. 3. 1 cm above the ischial spines. 4. in no relationship to the ischial spines.

3. 1 cm above the ischial spines. Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as -1, -2, or -3. A presenting part below the ischial spines, as +1, +2, or +3.

A nurse is obtaining a medication history from a client who suspects she's pregnant. At which week of gestation does placental transport of substances to and from the fetus begin? 1. 1st week 2. 2nd week 3. 5th week 4. 8th week

3. 5th week Placental transport of substances to and from the fetus begins in the 5th week.

A client is recovering in the labor and delivery area after delivering a 6-lb, 3-oz boy. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings? 1. A boggy uterus 2. Normal involution 3. A vaginal laceration 4. A clotting problem

3. A vaginal laceration A steady trickle of blood on the perineal pad of a client with a well-contracted uterus may indicate a vaginal, cervical, or perineal laceration. A boggy uterus would be palpable above the umbilicus and would be soft and poorly contracted. With normal involution, the perineal pad would show only lochia, not a trickle of blood. A clotting problem causes more than a steady trickle of blood and probably would have been identified earlier during labor.

Which of the following would be inappropriate to include in the care plan for a client during the fourth stage of labor? 1. Vital signs and fundal checks every 15 minutes 2. Time with the baby to initiate breast-feeding 3. Catheterization to protect the bladder from trauma 4. Perineal assessments for swelling and bleeding

3. Catheterization to protect the bladder from trauma Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the care plan during the fourth stage of labor.

A 15-year-old client delivers a healthy neonate. The neonate's teenage father arrives on the unit demanding to see his baby. Both sets of grandparents are present and asking to see the newly delivered baby. The newly hired nurse assigned to the nursery should take which action? 1. Notify security because the baby's father is demanding to see his baby. 2. Teach the grandparents how to scrub and gown before entering the nursery. 3. Discuss the unit's policy with the charge nurse. 4. Invite everyone into the large conference room to see the baby.

3. Discuss the unit's policy with the charge nurse. Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the baby's parents are married or if the mother is an emancipated minor. Therefore, the teenage mother may not be able to legally make her own decisions about her parents' (the baby's grandparents') presence. She or her parents do have a say as to whether the father's parents can visit. The mother of the baby does have a say in visitors seeing her neonate. Because the family dynamics aren't clear in this scenario, the best answer would be to check with the charge nurse who knows the unit's policy. Although the baby's father may have demanded to see the baby, the question doesn't indicate violent or threatening behavior; therefore, notifying security isn't necessary. The nurse can instruct the father's parents on how to gown and glove before visiting the baby if they have permission to visit. Because the family dynamics aren't known, inviting everyone to gather in a conference room isn't advisable.

While caring for a healthy female neonate, the nurse notices red stains on the diaper after the baby voids. Which action should the nurse take next? 1. Call the physician to report the problem. 2. Encourage the mother to feed the baby to decrease dehydration. 3. Do nothing because this is normal. 4. Check the baby's urine for hematuria.

3. Do nothing because this is normal. Female neonates may have some vaginal bleeding in the 1st or 2nd day after birth because they no longer have the high levels of female hormones that they were exposed to while in the uterus. The physician needn't be called. This bleeding is normal and doesn't indicate dehydration or hematuria.

Which condition could a mother have and still be allowed to breast-feed her child? 1. Positive for human immunodeficiency virus (HIV) 2. Active tuberculosis (TB) 3. Endometritis 4. Cardiac disease

3. Endometritis Of the listed conditions, endometritis is the only one in which a mother can continue to breast-feed provided that the antibiotics she's taking aren't contraindicated in breast-feeding. A mother who has HIV or active TB is strongly discouraged from breast-feeding because of concerns about transmitting the infection to the neonate. Clients with cardiac disease are also discouraged from breast-feeding because of the strain on the mother's defective heart.

The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary? 1. Increased maternal blood pressure of 150/90 mm Hg 2. Decreased amount of vaginal bleeding 3. Fetal heart rate of 80 beats/minute 4. Maternal heart rate of 65 beats/minute

3. Fetal heart rate of 80 beats/minute A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean section to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.

The nurse assesses a 1-day-old neonate. Which finding indicates that the neonate's oxygen needs are not being met by current treatment? 1. Respiratory rate of 54 breaths/minute 2. Abdominal breathing 3. Nasal flaring 4. Acrocyanosis

3. Nasal flaring Signs of respiratory distress include a respiratory rate above 60 breaths/minute, labored respirations, grunting, nasal flaring, generalized cyanosis, and retractions. Abdominal breathing is a normal finding in neonates. Acrocyanosis (a bluish tinge to the hands and feet) is normal on the 1st day after birth.

A nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3. Prepare an ice pack for application to the area. A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

A postpartum client is ready for discharge. During discharge preparation, the nurse should instruct her to report which of the following to her primary health care provider? 1. Episiotomy discomfort 2. Lochia alba at 2 weeks' postpartum 3. Redness, warmth, and pain in the breasts 4. A temperature of 99.2° F (37.3° C) for 24 hours or more

3. Redness, warmth, and pain in the breasts Redness, warmth, and pain in the breasts indicate mastitis. Typically accompanied by fever, headache, and flulike symptoms, mastitis usually occurs 2 to 3 weeks after delivery. Episiotomy discomfort sometimes persists for up to 6 weeks, depending on the extent of trauma. Lochia alba is normal at 2 weeks' postpartum. A temperature of 99.2° F (37.3° C) isn't significant.

A nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which of the following, if stated by the client, would indicate a need for further instructions? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast-feeding." 4. "I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water." Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of handwashing and that she should breast-feed every 2 to 3 hours.

A nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. The best response by the nurse would be: 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn to prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K- deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.

The nurse determines that a client is in false labor. After obtaining discharge orders from the nurse-midwife, the nurse provides discharge teaching to the client. Which instruction is most appropriate at this time? 1. "Drink coffee or tea to maintain hydration." 2. "Apply cold compresses to relieve discomfort." 3. "Maintain a supine position to promote rest." 4. "Return to the facility if fever occurs."

4. "Return to the facility if fever occurs." The nurse should instruct a client in false labor to return to the health care facility if she develops signs or symptoms of infection, such as a fever; if her membranes rupture; if vaginal bleeding occurs; or if her contractions become more intense. The nurse should suggest warm milk or herbal tea, which promote relaxation and rest, instead of coffee or caffeinated tea. Taking a warm tub bath or shower — not applying cold compresses — helps relieve discomfort. A semi-upright position with pillows placed under the client's knees promotes rest.

A pregnant client comes to the facility for her first prenatal visit. After obtaining her health history and performing a physical examination, the nurse reviews the client's laboratory test results. Which findings suggest iron deficiency anemia? 1. Hemoglobin (Hb) 15 g/L; hematocrit (HCT) 33% 2. Hb 13 g/L; HCT 32% 3. Hb 10 g/L; HCT 35% 4. Hb 9 g/L; HCT 30%

4. Hb 9 g/L; HCT 30% With iron deficiency anemia, the Hb level is below 11 g/L and HCT drops below 32%.

The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What is the best response by the nurse? 1. "Why don't you wait and see how things go? You may be tired of breast-feeding by then." 2. "Let your day-care provider give the baby formula in a bottle, then breast-feed when you're home." 3. "Your baby won't need breast-feeding by then, so just switch completely to formula when you return to work." 4. "You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."

4. "You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle." Breast-feeding should continue for the first 6 months after birth when possible. Breast milk can be pumped at work to give to the baby at the day-care center. This will also keep the mother's milk production up.

A client is at her ideal weight when she conceives. During a prenatal visit 2 months later, she asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response? 1. "You should gain less than 10 lb." 2. "You should gain 10 to 15 lb." 3. "You should gain 16 to 24 lb." 4. "You should gain 24 to 32 lb."

4. "You should gain 24 to 32 lb." For a client entering pregnancy in her ideal weight range, a gain of 24 to 32 lb (11 to 15 kg) is adequate to meet her needs and the needs of her fetus. Weight gain below the recommended range predisposes the client to complications during pregnancy, labor, and delivery.

A nulliparous client has been in the latent phase of the first stage of labor for several hours. Despite continued uterine contractions, her cervix hasn't dilated further since the initial examination. Her latent phase may be considered prolonged after: 1. 6 hours. 2. 10 hours. 3. 14 hours. 4. 20 hours.

4. 20 hours. Based on research, the latent phase may be considered prolonged if it exceeds 20 hours in a nulliparous client or 14 hours in a multiparous client.

A nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large fetus after oxytocin (Pitocin) induction

4. A multiparous client who delivered a large fetus after oxytocin (Pitocin) induction The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix , perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than the other clients. Additionally, there are no specific data in the client descriptions in options 1, 2, or 3 that present the risk for hemorrhage.

The nurse assesses a client for signs and symptoms of ectopic pregnancy. What is the most common finding associated with this antepartum complication? 1. Temperature elevation 2. Vaginal bleeding 3. Nausea and vomiting 4. Abdominal pain

4. Abdominal pain Abdominal pain is the most common finding in ectopic pregnancy, occurring in over 90% of women with this antepartum complication. Temperature elevation, vaginal bleeding, and nausea and vomiting are less commonly associated with ectopic pregnancy.

A breast-feeding client is diagnosed with mastitis. Which nursing intervention would be most helpful to her? 1. Instructing her to breast-feed the neonate at least every 4 hours 2. Teaching her to apply a cold compress to the affected breast after each feeding 3. Recommending that she wear a special brassiere when breast-feeding 4. Advising her to massage the affected area gently while breast-feeding

4. Advising her to massage the affected area gently while breast-feeding To help relieve mastitis, the nurse should advise the client to massage the affected area gently during breast-feeding; breast-feed at least every 2 to 3 hours; apply a warm, wet washcloth to her breast before each feeding; and avoid wearing a brassiere when breast-feeding.

Rho(D) immune globulin (RhoGAM) is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

4. Being affected by Rh incompatibility Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus' Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin (RhoGAM) prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful? 1. Placing the baby flat during feedings 2. Providing fluids with a small spoon 3. Placing the nipple in the cleft palate 4. Burping the baby frequently

4. Burping the baby frequently Because a baby with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. A baby with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons aren't used. A baby with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration.

A client with active genital herpes is admitted to the labor and delivery area during the first stage of labor. Which type of birth should the nurse anticipate for this client? 1. Mid forceps 2. Low forceps 3. Induction 4. Cesarean

4. Cesarean For a client with active genital herpes, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Mid forceps and low forceps are types of vaginal births that could transmit the herpes infection to the neonate. Induction is used only during vaginal birth; therefore, it's inappropriate for this client.

The State Health Department notifies the nursery staff nurse of a phenylketonuria (PKU) metabolic screening test result of 7 mg/dl for a neonate discharged several days ago. What should the nursery nurse do? 1. Notify the parents and tell them to take the neonate to the closest hospital for charcoal administration. 2. Notify the physician in the morning of the normal test result. 3. Notify the blood bank because the neonate requires a blood transfusion. 4. Immediately notify the physician because the test result is critically elevated.

4. Immediately notify the physician because the test result is critically elevated. A normal test result for phenylketonuria metabolic screening is < 2 mg/dl; a level of 7 mg/dl is critically elevated. The nurse should immediately notify the physician. The physician should then notify the parents and ask them to bring the neonate to the facility for immediate evaluation. The neonate should have a definitive serum test performed and should be evaluated by a pediatrician who specializes in inborn errors of metabolism such as PKU. Early intervention prevents mental retardation that can occur as a result of PKU. The test result isn't normal and waiting to notify the physician in the morning delays treatment. Charcoal is administered to neutralize poison ingestion, not to treat PKU. Blood transfusions aren't indicated for PKU.

A pregnant client's last menstrual period began on October 12. The nurse calculates the estimated date of delivery (EDD) as: 1. June 5. 2. June 19. 3. July 5. 4. July 19.

4. July 19. Using Nägele's rule, the nurse calculates the client's EDD by adding 7 days to the 1st day of the last menstrual period (12 + 7 = 19) and subtracting 3 months from the month of the last menstrual period (October - 3 months = July). This results in an EDD of July 19.

A client is experiencing an early postpartum hemorrhage. Which action would be inappropriate? 1. Inserting an indwelling urinary catheter 2. Fundal massage 3. Administration of oxytocics 4. Pad count

4. Pad count By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.

At birth, a neonate weighs 7 lb, 3 oz. When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan? 1. Imbalanced nutrition: Less than body requirements related to inadequate feeding 2. Hypothermia related to immature temperature regulation 3. Deficient fluid volume related to insensible fluid loss 4. Risk for injury related to hyperbilirubinemia

4. Risk for injury related to hyperbilirubinemia Yellow sclerae indicate bilirubin deposits and possible hyperbilirubinemia. The nurse should add a diagnosis of Risk for injury related to hyperbilirubinemia to the care plan because bilirubinemia may cause bilirubin encephalopathy (kernicterus). The assessment findings don't support a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to inadequate feeding because neonates normally breast-feed every 2 to 3 hours. An axillary temperature of 98° F (36.7° C) is within normal limits for a neonate, eliminating Hypothermia as a nursing diagnosis. Loss of up to 10% of birth weight is normal in neonates, making a diagnosis of Deficient fluid volume inappropriate.

A breast-feeding baby will turn his head toward the mother's breast in a natural instinct to find food. What is the name of this reflex? 1. Tonic neck reflex 2. Moro's reflex 3. Grasp reflex 4. Rooting reflex

4. Rooting reflex The rooting reflex is an infant's response to having his cheek stroked. The infant will turn his head to the side of the stroked cheek and will open his mouth in anticipation of having a nipple placed in it. The tonic neck reflex is elicited by turning the neonate's head to the side when he's lying on his back. The extremities on the same side extend and those on the other side flex. Moro's reflex is the startle reflex. For example, when the neonate's crib is jolted, the neonate abducts his arms and extends them. The grasp reflex occurs when the neonate curls his fingers around another person's fingers.

Which of the following would be inappropriate to assess in a mother who's breast-feeding? 1. The attachment of the baby to the breast 2. The mother's comfort level with positioning the baby 3. Audible swallowing 4. The baby's lips smacking

4. The baby's lips smacking Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who's smacking his lips isn't well attached and can injure the mother's nipples.

Vaginal discharge in pregnancy

Can occur in the first through the third trimesters Caused by hypertrophy and thickening of the vaginal mucosa and increased mucus production

False Labor

False labor does not produce dilation, effacement, or descent. Contractions are irregular, without progression. Activity, such as walking, often relieves false labor.

LOA

Left occipitoanterior

LOP

Left occipitoposterior

LOT

Left occipitotransverse

LSA

Left sacroanterior

LSP

Left sacroposterior

Nasal stuffiness in pregnancy

Occurs in the first through third trimesters Results from increased estrogen, which causes swelling of the nasal tissues and dryness

Nausea and vomiting in pregnancy (when/cause)

Occurs in the first trimester and subsides by the third month Caused by elevated levels of human chorionic gonadotropin and changes in carbohydrate metabolism

Contraction stress test

Test assesses placental oxygenation and function. Test determines fetal ability to tolerate labor and determines fetal well-being. Fetus is exposed to the stress of contractions to assess the adequacy of placental perfusion under simulated labor conditions. Test is performed if nonstress test is abnormal.

Fern test

The fern test is a microscopic slide test to determine the presence of amniotic fluid leakage. Using sterile technique, a specimen is obtained from the external os of the cervix and vaginal pool and is examined on a slide under a microscope. A fern-like pattern produced by the effects of salts of the amniotic fluid indicates the presence of amniotic fluid.

Constipation in pregnancy

Usually occurs in the second and the third trimesters Results from an increase in progesterone production, decreased intestinal motility, displacement of the intestines, pressure of the uterus, and taking iron supplements

Variable decelerations

Variable decelerations are caused by conditions that restrict flow through the umbilical cord. Variable decelerations do not have the uniform appearance of early and late decelerations. The shape, duration, and degree of decline below baseline FHR are variable; these fall and rise abruptly with the onset and relief of cord compression. Variable decelerations also may be nonperiodic, occurring at times unrelated to contractions. Baseline rate and variability are considered when evaluating variable decelerations. Variable decelerations are significant when FHR repeatedly declines to less than 70 beats/ min and persists at that level for at least 60 seconds before returning to baseline.

Discharge planning is being finalized for a neonate who was born at 32-weeks' gestation and was diagnosed with retinopathy of prematurity. What should the nurse tell the parents? 1. "An ophthalmologist will examine the baby before discharge." 2. "You should schedule an appointment with a optometrist when the baby is six months old. 3. "Before your child enters the public school system you must arrange for an individualized educational plan with the school nurse." 4. "Contact the local support group for the blind."

1. "An ophthalmologist will examine the baby before discharge." An ophthalmologist commonly examines neonates with retinopathy of prematurity before discharge. Serial eye examinations are then necessary to determine the extent of damage. An optometrist can't provide follow-up treatment for the neonate with retinopathy of prematurity because some neonates require cryotherapy and laser photocoagulation therapy, both of which must be performed by an ophthalmologist. The parents should contact the early intervention program to set up an individualized educational plan for their child before he reaches school age. Because the neonate may have permanent vision loss, intervention before school age is important to the child's growth and development. The school nurse is only involved with individualized educational plans for children of school age. The neonate may not be blind, so suggesting a support group for the blind is inappropriate.

A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which of the following responses best indicates the normal neonate's breast-feeding behavior? 1. "Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings." 2. "Let me call the lactation consultant to make sure that your baby is feeding properly." 3. "Don't worry; your baby is an aggressive feeder and needs a lot of sucking satisfaction." 4. "It seems as if your baby is hungry. Why don't you provide your baby with formula after the feeding to make sure he's getting enough nourishment?"

1. "Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings." Breast milk is the ideal food for a neonate. As a result, the neonate will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother's breast-feeding attempts are unsatisfactory. Nurses shouldn't suggest giving formula to a breast-feeding neonate.

After a vaginal delivery, a postpartum client complains of perineal discomfort when sitting. To promote comfort, the nurse should provide which instruction? 1. "Contract your buttocks before sitting or rising." 2. "Support your body weight on the arms of a chair." 3. "Place a pillow behind your back." 4. "Sit on an inflatable ring."

1. "Contract your buttocks before sitting or rising." Tensing the buttocks before sitting or rising may ease edema, ecchymosis, or other discomfort caused by perineal sutures; the client should maintain the tension briefly. Supporting body weight on the arms of a chair strains the client's arms and prevents her from assuming a full, comfortable sitting position. Placing a pillow behind her back may cause her to lean forward, putting even more pressure on the perineum. Sitting on an inflatable ring relieves pressure on some areas of the perineum but places more pressure on others.

A client who tested positive for the human immunodeficiency virus (HIV) requests that the nursery staff use cloth diapers that she brought from home to diaper her infant. The client says that cloth diapers are necessary because of a family history of allergies and skin conditions. Which response by the nurse is best? 1. "Disposable diapers are necessary because they effectively contain urine and stool." 2. "Prewashed cloth diapers are an excellent choice for this infant." 3. "If you choose cloth diapers, then you must perform all of the diaper changes." 4. "Cloth diapers are acceptable as long as they are covered with plastic pants."

1. "Disposable diapers are necessary because they effectively contain urine and stool." The nurse should respond by telling the mother that disposable diapers are necessary because they effectively contain urine and stool. Cloth diapers sometimes leak urine and stool, both of which pose a danger to the staff and other infants. Cloth diapers shouldn't be used regardless of who changes the diaper. Even with plastic pants covering them, cloth diapers still pose a hazard.

A nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which of the following statements? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily." The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast -feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications.

A clinic nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? 1. "I should wear panty hose." 2. "I should wear support hose." 3. "I should wear flat nonslip shoes that have good support." 4. "I should wear knee -high hose, but I should not leave them on longer than 8 hours."

1. "I should wear panty hose." Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and to minimize falls.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2. "My insulin dose will likely need to be increased during the second and third trimesters." 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4. "My insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding."

1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy.

On the 2nd postpartum day, a client tells the nurse she feels anxious and tearful. Which response by the nurse would be appropriate? 1. "It isn't unusual to have those feelings after delivery." 2. "How have you coped with other problems in your life?" 3. "To whom do you usually talk when you have problems?" 4. "Don't worry. You'll be fine."

1. "It isn't unusual to have those feelings after delivery." Approximately 50% to 70% of postpartum clients experience transient depression during the first 7 to 10 days after delivery. The nurse should ask about the client's previous coping mechanisms and current support persons only after assuring her that her feelings are expected. Telling the client she'll be fine blocks further communication.

A stillborn infant was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the infant. Which statement by the nurse would further assist the family in their initial period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

1. "What can I do for you?" When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their physician or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques . The nurse must also consider cultural and religious practices and beliefs. Option 1 provides a supportive, giving , and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

A client has just completed the fourth stage of labor. The nurse in the postpartum unit receives report from the labor and delivery nurse. The report includes the following information: temperature 97° F (36.2° C), pulse 50 beats/minute, respiratory rate 16 breaths/minute, white blood cell (WBC) count 17,000/μl, hemoglobin 12 g/dl, and hematocrit 34%. Which instruction should the nurse give to the labor and delivery nurse? 1. "You may transfer the client to us now." 2. "Make sure you notify the physician that the client is showing signs of infection before you transfer her." 3. "You may transfer the client after she delivers the placenta." 4. "Make sure you draw anaerobic and aerobic blood cultures before you transfer the client to our unit."

1. "You may transfer the client to us now." The report from the labor and delivery nurse indicates that the client is stable after delivery and is ready for transfer to the postpartum unit. Normal WBC count after delivery ranges from10,000 to 18,000/μl. The client doesn't show signs of infection; therefore, drawing blood cultures and notifying the physician of signs of infection aren't necessary. The placenta is delivered during the third stage of labor. This client is in the fourth stage of labor, which encompasses the time when the mother's body stabilizes after delivery.

A nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn infant after delivery. The client asks the nurse about the feeding options that are available. The best response by the nurse is: 1. "You will need to bottle-feed the newborn infant." 2. "You will need to feed the newborn infant by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1. "You will need to bottle-feed the newborn infant." Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartal period, during labor and birth , or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

A pregnant client asks the nurse about the percentage of congenital anomalies caused by drug exposure. How should the nurse respond? 1. 1% 2. 10% 3. 20% 4. 60%

1. 1% Drug exposure causes 1% of congenital anomalies.

A client has just begun taking an oral contraceptive that contains estrogen and progestin. The nurse should explain that full contraceptive benefits won't occur until the client has taken the drug for at least: 1. 10 days. 2. 2 weeks. 3. 1 month. 4. 2 months.

1. 10 days. Because of the mechanism of action of oral contraceptives, the onset of action is somewhat delayed. Full contraceptive benefits don't occur until an oral contraceptive agent has been taken for at least 10 days.

Which of the following is normal calorie intake for a neonate? 1. 110 to 130 calories per kg 2. 30 to 40 calories per lb of body weight 3. At least 2 ml per feeding 4. 90 to 100 calories per kg

1. 110 to 130 calories per kg Calories per kg is the accepted way of determine appropriate nutritional intake for a neonate. The recommended calorie requirement is 110 to 130 calories per kg of the neonate's body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development.

A client who's a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. The client's cervical examination would reveal which of the following? 1. 2 cm dilated; 100% effaced at 0 station 2. 4 to 5 cm dilated; 80% effaced at -1 station 3. 2 cm dilated; 50% effaced at +1 station 4. 3 cm dilated; 50% effaced at 0 station

1. 2 cm dilated; 100% effaced at 0 station The nurse must distinguish between the primigravida and multigravida cervical dilation to make a care plan for the laboring client. Primigravidas will efface and then dilate, while multigravidas will efface and dilate at the same time.

An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large infants, to shorten the second stage of labor, or for a malpresentation. The nurse caring for the mother following an assisted birth should keep which of the following in mind? 1. A vacuum extractor is safer than forceps because it causes less trauma to the baby and the mother's perineum. 2. The baby will develop a cephalohematoma as a result of the instrumentation. 3. The use of instruments during the birth process is a fairly rare occurrence. 4. Additional nursing interventions are needed to ensure an uncomplicated postpartum.

1. A vacuum extractor is safer than forceps because it causes less trauma to the baby and the mother's perineum. When used properly, a vacuum extractor is a safer delivery with fewer complications for the mother and the baby than a forceps delivery. Cephalohematomas occur more often in assisted births than in unassisted births. Instruments are used during delivery when individually necessary. No additional nursing interventions are needed during the postpartum period.

Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy? 1. Abdominal pain, vaginal bleeding, and a positive pregnancy test 2. Hyperemesis and weight loss 3. Amenorrhea and a negative pregnancy test 4. Copious discharge of clear mucous and prolonged epigastric pain

1. Abdominal pain, vaginal bleeding, and a positive pregnancy test Abdominal pain, vaginal bleeding, and a positive pregnancy test are cardinal signs of an ectopic pregnancy. Nausea and vomiting may occur prior to rupture but significantly increase after rupture. Amenorrhea and a negative pregnancy test may indicate another type of metabolic disorder such as hypothyroidism. Discharge of clear mucous isn't indicative of an ectopic pregnancy and referred shoulder pain, not epigastric pain, should be expected.

Where is the best place for the nurse to detect fetal heart sounds for a client in the first trimester of pregnancy? 1. Above the symphysis pubis 2. Below the symphysis pubis 3. Above the umbilicus 4. At the umbilicus

1. Above the symphysis pubis In the first trimester, fetal heart sounds are loudest in the area of maximum intensity, just above the client's symphysis pubis at the midline. Fetal heart sounds aren't heard as well in the other locations.

A nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing diagnosis for this client? 1. Acute pain 2. Disturbed body image 3. Impaired urinary elimination 4. Risk for imbalanced fluid volume

1. Acute pain The priority nursing diagnosis for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is Acute pain. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate the presence of Disturbed body image, Impaired urinary elimination, or Risk for imbalanced fluid volume.

A nurse in the labor room is caring for a client in the active stage of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The appropriate nursing action is to: 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin (Pitocin) intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns.

1. Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/ min via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication . Although the nurse would document the occurrence, option 4 would delay necessary treatment.

The nurse is assessing a client who's 6 weeks pregnant. Which findings best support a suspicion of ectopic pregnancy? 1. Amenorrhea and adnexal fullness and tenderness 2. Nausea, vomiting, and slight uterine enlargement 3. Grapefruit-size uterine enlargement and vaginal spotting 4. Amenorrhea, sudden weight gain, and audible fetal heart tones above the symphysis pubis

1. Amenorrhea and adnexal fullness and tenderness Signs and symptoms of ectopic pregnancy include amenorrhea and adnexal fullness and tenderness. Nausea, vomiting, and vaginal spotting may occur in ectopic pregnancy, but the uterus doesn't enlarge because it remains empty. Weight gain may accompany ectopic pregnancy; however, fetal heart tones aren't audible above the symphysis pubis in clients with this disorder.

During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse should instruct the client to push the control button at which time? 1. At the beginning of each fetal movement 2. At the beginning of each contraction 3. After every three fetal movements 4. At the end of fetal movement

1. At the beginning of each fetal movement An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldn't allow accurate comparison of fetal movement and FHR changes.

The nurse is administering oxytocin (Pitocin) to a client in labor. During oxytocin therapy, why must the nurse monitor the client's fluid intake and output closely? 1. Because oxytocin causes fluid retention 2. Because oxytocin causes excessive thirst 3. Because oxytocin has a diuretic effect 4. Because oxytocin is toxic to the kidney

1. Because oxytocin causes fluid retention Oxytocin has an antidiuretic effect; prolonged I.V. infusion may lead to severe fluid retention, resulting in seizures, coma, and even death. Excessive thirst results from the work of labor and lack of oral fluids, not oxytocin administration. Oxytocin isn't toxic to the kidney.

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed? 1. Betamethasone 2. Nalbuphine (Nubain) 3. Rho(D) immune globulin (RhoGAM) 4. Dinoprostone (Cervidil vaginal insert)

1. Betamethasone Betamethasone , a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine (Nubain) is an opioid analgesic. Rho(D) immune globulin (RhoGAM) is given to Rh-negative clients to prevent sensitization. Dinoprostone (Cervidil vaginal insert) is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.

During labor, a client asks the nurse why her blood pressure must be measured so often. Which explanation should the nurse provide? 1. Blood pressure reflects changes in cardiovascular function, which may affect the fetus. 2. Increased blood pressure indicates that the client is experiencing pain. 3. Increased blood pressure signals the peak of the contraction. 4. Medications given during labor affect blood pressure.

1. Blood pressure reflects changes in cardiovascular function, which may affect the fetus. Frequent blood pressure measurement helps determine whether maternal cardiovascular function is adequate. During contractions, blood flow to the intervillous spaces changes, compromising fetal blood supply. Increased blood pressure is expected during pain and contractions. Measuring blood pressure frequently helps determine whether blood pressure has returned to precontraction levels, ensuring adequate blood flow to the fetus. Although medications given during labor can affect blood pressure, the main purpose of measuring blood pressure is to verify adequate fetal status.

A client who's 16 weeks pregnant comes to the emergency department complaining of vaginal bleeding. Which statement accurately describes estrogen and progesterone levels during this client's stage of pregnancy? 1. Both estrogen and progesterone levels are rising. 2. The estrogen level is much higher than the progesterone level. 3. Both estrogen and progesterone levels are declining. 4. The estrogen level is much lower than the progesterone level.

1. Both estrogen and progesterone levels are rising. Until the 7th month of pregnancy, both estrogen and progesterone are secreted in progressively greater amounts. Between the 7th and 9th months, estrogen secretion continues to increase while progesterone secretion drops slightly. This increasing estrogen-progesterone ratio promotes the onset of uterine contractions.

A client who's pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she's apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing: 1. Braxton Hicks contractions. 2. back labor. 3. fetal distress. 4. true labor contractions.

1. Braxton Hicks contractions. Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout pregnancy, they're most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3 to 4 months in multiparous clients. Back labor refers to pain that typically starts in the back. Fetal distress doesn't cause contractions, although it may cause sharp abdominal pain. Decreased or absent fetal movements, green-tinged or yellowish green-tinged fluid, or port-wine-colored fluid may also indicate fetal distress. Pain from true labor contractions typically starts in the back and moves to the front of the fundus as a band of pressure that peaks and subsides in a regular pattern.

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation? 1. Breech position 2. Late decelerations 3. Entrance into the second stage of labor 4. Multiple gestation

1. Breech position Fetal heart sounds in the upper right quadrant and meconium-stained amniotic fluid indicate a breech presentation. The staining is usually caused by the squeezing actions of the uterus on a fetus in the breech position, although late decelerations, entrance into the second stage of labor, and multiple gestation may contribute to meconium-stained amniotic fluid.

The mother of a newborn calls a clinic and reports to a nurse that when cleaning the umbilical cord, the mother noticed that the cord was moist and that discharge was present . The appropriate nursing instruction to the mother is which of the following? 1. Bring the infant to the clinic. 2. This is a normal occurrence. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

1. Bring the infant to the clinic. Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the client should be instructed to notify a health care provider. If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given in the question.

A 2-day-old neonate hasn't been eating well, is irritable, and has a temperature of 101° F axillary. The nursery nurse anticipates that the physician will most likely prescribe which tests? 1. Cerebrospinal fluid (CSF) and blood cultures and a complete blood count (CBC) 2. Urinalysis 3. Blood culture and a throat culture 4. CBC and arterial blood gas analysis

1. Cerebrospinal fluid (CSF) and blood cultures and a complete blood count (CBC) The neonate is exhibiting signs and symptoms of sepsis. Effective treatment of sepsis can't be initiated until the cause is identified. The physician will most likely prescribe CBC and obtain CSF and blood cultures to help identify the cause. Urinalysis would indicate whether a urinary tract infection (UTI) is present but it won't identify the cause. Arterial blood gas analysis isn't necessary for this neonate at this time.

The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? 1. Change the client's position. 2. Prepare for emergency cesarean section. 3. Check for placenta previa. 4. Administer oxygen.

1. Change the client's position. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression.

A nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1. Changes in vital signs Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

The nurse is caring for a client who's in labor. The physician still isn't present. After the baby's head is delivered, which nursing intervention would be most appropriate? 1. Checking for the umbilical cord around the baby's neck 2. Placing antibiotic ointment in the baby's eyes 3. Turning the baby's head to the side to drain secretions 4. Assessing the baby for respirations

1. Checking for the umbilical cord around the baby's neck After the baby's head is delivered, the nurse should check for the cord around the baby's neck. If the cord is around the neck, it should be gently lifted over the baby's head. Antibiotic ointment is administered to the baby after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The baby's head isn't turned during delivery. After delivery, the baby is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the baby's mouth. Assessing the baby's respiratory status should be done immediately after delivery.

After delivering an 8 lb (3.6 kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of: 1. sterile water. 2. glucose water. 3. standard infant formula. 4. enriched infant formula.

1. sterile water. For a bottle-fed neonate, the first feeding usually consists of sterile water, which is less irritating than glucose water or infant formula if aspirated.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present . Based on these findings, the nurse would prepare the client for: 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bedrest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

1. Delivery of the fetus Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae.

As she tries to decide on a birth-control method, a client requests information about medroxyprogesterone (Depo-Provera). Which of the following represents the nurse's best response? 1. Depo-Provera needs to be administered every 12 weeks. 2. Depo-Provera is effective for only 2 months at a time. 3. Depo-Provera can't be given to breast-feeding women. 4. Depo-Provera has a high failure rate; use a barrier form of protection also.

1. Depo-Provera needs to be administered every 12 weeks. Depo-Provera will provide effective birth control for 3 months, and it may be the birth-control method of choice for clients who are breast-feeding because studies haven't established any contraindications. There is no evidence that the drug has a high failure rate.

A diabetic client in labor tells the nurse she has had trouble controlling her blood glucose level recently. She says she didn't take her insulin when the contractions began because she felt nauseated; about an hour later, when she felt better, she ate some soup and crackers but didn't take insulin. Now, she reports increased nausea and a flushed feeling. The nurse notes a fruity odor to her breath. What do these findings suggest? 1. Diabetic ketoacidosis 2. Hypoglycemia 3. Infection 4. Transition to the active phase of labor

1. Diabetic ketoacidosis Signs and symptoms of diabetic ketoacidosis include nausea and vomiting, a fruity or acetone breath odor, signs of dehydration (such as flushed, dry skin), hyperglycemia, ketonuria, hypotension, deep and rapid respirations, and a decreased level of consciousness. In contrast, hypoglycemia causes sweating, tremors, palpitations, and behavioral changes. Infection causes a fever. Transition to the active phase of labor is signaled by cervical dilation of up to 7 cm and contractions every 2 to 5 minutes.

When auscultating the heart sounds of a client who's 34 weeks pregnant, the nurse detects a systolic ejection murmur. Which action should the nurse take? 1. Document the finding, which is normal during pregnancy. 2. Consult with a cardiologist. 3. Contact the client's primary health care provider. 4. Explain that this finding may indicate a cardiac disorder.

1. Document the finding, which is normal during pregnancy. During pregnancy, a systolic ejection murmur over the pulmonic area is a common finding. Typically, it results from increases in blood volume and cardiac output, along with changes in heart size and position. Other cardiac rhythm disturbances also may occur during pregnancy and don't require treatment unless the client has concurrent heart disease. The nurse should document the finding and check for the murmur during the next visit. The nurse need not consult a cardiologist or the primary care health provider and shouldn't tell the client that this finding indicates a cardiac disorder.

A client in labor tells the nurse-midwife that she feels a strong urge to push. Physical examination reveals that her cervix is not completely dilated. The nurse-midwife tells her not to push yet. What is the rationale for this instruction? 1. Early pushing may cause edema and impede fetal descent. 2. The nurse-midwife isn't ready to assist her. 3. The fetus hasn't rotated into the proper position. 4. Pushing at this time may cause rupture of the membranes.

1. Early pushing may cause edema and impede fetal descent. Pushing (bearing down) before the cervix is completely dilated may cause edema and tissue damage and may impede fetal descent. Telling the client not to push because the nurse-midwife isn't ready to assist is inappropriate and unprofessional. If the cervix were completely dilated, the nurse-midwife could assist the client in changing position to help reposition the fetus. The client's membranes should have ruptured already.

During a routine prenatal visit, a pregnant client reports heartburn. To minimize her discomfort, the nurse should include which suggestion in the care plan? 1. Eat small, frequent meals. 2. Limit fluid intake sharply. 3. Drink more citrus juice. 4. Take sodium bicarbonate.

1. Eat small, frequent meals. To relieve heartburn, the nurse should advise a pregnant client to eat smaller meals at shorter intervals; drink six to eight 8-oz glasses of fluid daily to minimize regurgitation and reflux of stomach contents; avoid citrus juice, which may act as a gastric irritant and worsen heartburn; and avoid sodium bicarbonate, which may disrupt the body's sodium-potassium balance.

A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit? 1. Edema 2. Pelvic adequacy 3. Rh factor changes 4. Hemoglobin alterations

1. Edema At each prenatal visit, the nurse should assess the client for edema because edema, increased blood pressure, and proteinuria are cardinal signs of pregnancy-induced hypertension. Pelvic measurements and Rh typing are determined at the first visit only because they don't change. The nurse should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation.

Steps to Take if Umbilical Cord Prolapse Is Suspected

1. Elevate the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand. 2. Place the client into extreme Trendelenburg's or modified Sims' position or a knee-chest position. 3. Administer oxygen, 8 to 10 L/ min, by face mask to the client. 4. Monitor fetal heart rate and assess the fetus for hypoxia. 5. Prepare to start intravenous fluids or increase the rate of an existing solution. 6. Prepare for immediate birth. 7. Document the event, actions taken, and the client's response.

A client who is 32 weeks pregnant is being monitored in the antepartum unit for pregnancy-induced hypertension. She suddenly complains of continuous abdominal pain and vaginal bleeding. Which nursing interventions should be included in the care of this client? 1. Evaluate vital signs. 2. Prepare for vaginal delivery. 3. Reassure the client that she'll be able to continue the pregnancy. 4. Evaluate fetal heart tones. 5. Monitor the amount of vaginal bleeding. 6. Monitor intake and output.

1. Evaluate vital signs. 4. Evaluate fetal heart tones. 5. Monitor the amount of vaginal bleeding. 6. Monitor intake and output. The client's symptoms indicate that she's experiencing abruptio placentae. The nurse must immediately evaluate the mother's well-being by evaluating vital signs; evaluate the well-being of the fetus by auscultating fetal heart tones; monitor the amount of blood loss; and evaluate volume status by monitoring intake and output. After the severity of the abruption has been determined and blood and fluid have been replaced, prompt cesarean delivery of the fetus (not vaginal delivery) is indicated if the fetus is in distress.

When reviewing a fetal monitor strip, the nurse looks for reassuring and nonreassuring fetal heart rate (FHR) patterns. Which pattern is nonreassuring? 1. FHR that accelerates to baseline tachycardia 2. Baseline FHR that doesn't increase 3. Variable FHR pattern that begins and ends abruptly 4. Short-term variability that doesn't decrease

1. FHR that accelerates to baseline tachycardia In a nonreassuring pattern, the FHR accelerates to baseline tachycardia as the fetus attempts to compensate for a growing oxygen deficit. A reassuring variable pattern has an abrupt onset and end. The baseline FHR doesn't increase and short-term variability doesn't decrease.

At 15 weeks' gestation, a client is scheduled for a serum alpha-fetoprotein (AFP) test. Which maternal history finding best explains the need for this test? 1. Family history of spina bifida in a sister 2. Family history of Down syndrome on the father's side 3. History of gestational diabetes during a previous pregnancy 4. History of spotting during the 1st month of the current pregnancy

1. Family history of spina bifida in a sister An abnormally high AFP level in the client's serum or amniotic fluid suggests a neural tube defect such as spina bifida. A family history of such defects increases the risk of carrying a fetus with a neural tube defect. Although a low AFP level has been correlated with Down syndrome, it isn't the most accurate indicator. No known correlation exists between gestational diabetes or early vaginal spotting and a certain AFP level at 15 to 20 weeks' gestation.

A nurse is conducting a physical examination on a neonate. At which pulse point on a neonate would the absence of a palpable pulse indicate a possible coarctation of the aorta? 1. Femoral 2. Brachial 3. Radial 4. Carotid

1. Femoral With coarctation of the aorta, the nurse should note bounding pulses and increased blood pressure in the upper extremities, as well as decreased or absent pulses and lower blood pressure in the lower extremities. This is due to the narrowing of the aortic arch.

The nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? 1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry 2. Acidic pH of fluid when tested with nitrazine paper 3. Presence of amniotic fluid in the vagina 4. Cervical dilation of 6 cm 5. Alkaline pH of fluid when tested with nitrazine paper 6. Contractions occurring every 5 minutes

1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry 3. Presence of amniotic fluid in the vagina 5. Alkaline pH of fluid when tested with nitrazine paper The fernlike pattern that occurs when vaginal fluid is placed on a glass slide and allowed to dry, presence of amniotic fluid in the vagina, and alkaline pH of fluid are all signs of ruptured membranes. The fernlike pattern seen when the fluid is allowed to dry on a slide is a result of the high sodium and protein content of the amniotic fluid. The presence of amniotic fluid in the vagina results from the expulsion of the fluid from the amniotic sac. Cervical dilation and regular contractions are signs of progressing labor but don't indicate PROM.

Immediately after a delivery, the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding? 1. Fetal body flexion or extension 2. Maternal age, body frame, and weight 3. Maternal and paternal ethnic backgrounds 4. Maternal parity and gravidity

1. Fetal body flexion or extension Fetal attitude — the overall degree of body flexion or extension — determines the type of molding in the head of a neonate. Molding isn't influenced by maternal age, body frame, weight, parity, or gravidity or by maternal and paternal ethnic backgrounds.

Assessment findings for hydatidiform mole

1. Fetal heart rate not detectable 2. Vaginal bleeding , which may occur by the fourth week or not until the second trimester; may be bright red or dark brown in color and may be slight, profuse, or intermittent 3. Symptoms of gestational hypertension, such as elevated blood pressure, edema, and proteinuria, before the twentieth week of gestation 4. Fundal height greater than expected for gestational date 5. Elevated human chorionic gonadotropin levels 6. Characteristic snowstorm pattern shown on ultrasound

An appropriate for gestational age neonate should weigh: 1. between the 10th and the 90th percentiles for age. 2. at least 2,500 g (5 lb, 8 oz). 3. between 2,000 and 4,000 g (4 lb, 6 oz and 8 lb, 12 oz). 4. in the 50th percentile.

1. between the 10th and the 90th percentiles for age. Appropriate for gestational age neonate weights fall between the 10th and the 90th percentiles for age. Large for gestational age weight is above the 90th percentile, and small for gestational age is below the 10th percentile for age.

A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion? 1. Fetal heart rate variability within 5 to 10 beats/minute 2. Persistent fetal bradycardia 3. Late decelerations 4. Variable decelerations and sinusoidal pattern

1. Fetal heart rate variability within 5 to 10 beats/minute Fetal heart rate variability most reliably indicates uteroplacental and fetal perfusion; an average variability of 5 to 10 beats per minute is considered acceptable. Persistent fetal bradycardia may signal hypoxia, arrhythmias, or fetal cord compression. Late decelerations indicate decreased blood flow and oxygen to the intervillous spaces during uterine contractions — a nonreassuring pattern. Variable decelerations suggest umbilical cord compression; a sinusoidal pattern signals severe fetal anemia or asphyxiation.

When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following? 1. Fetal hypoxia 2. The contraction pattern 3. The status of a trapped cord 4. Maternal comfort

1. Fetal hypoxia These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort.

A client who is 41 weeks pregnant is about to undergo a biophysical profile (BPP) to evaluate her fetus's well-being. The nurse knows that which components are included in a BPP? 1. Fetal tone 2. Fetal breathing movements 3. Femur length 4. Amniotic fluid volume 5. Biparietal diameter 6. Crown-rump length

1. Fetal tone 2. Fetal breathing movements 4. Amniotic fluid volume The BPP is an ultrasound assessment of the fetus's well-being that includes the following components: nonstress test, fetal tone, fetal breathing, fetal motion, and quantity of amniotic fluid. Crown-rump length is used to assess gestational age and is done during the first trimester. Measurements of the biparietal diameter and femur length are also used to assess gestational age and are done in the second and third trimesters.

A nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse monitors for which adverse reactions of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1. Flushing 4. Depressed respirations 5. Extreme muscle weakness Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

The nursery nurse just received the shift report. Which neonate should the nurse assess first? 1. Four-hour-old term neonate with jaundice 2. Two-day-old term neonate in an open bassinette 3. Six-day-old neonate in an isolette, whose gestational age assessment places him at 36 weeks gestation 4. Twelve-hour-old term neonate who is small for gestational age

1. Four-hour-old term neonate with jaundice The nurse should assess the four-hour-old neonate with jaundice. When jaundice occurs within the first 24 hours of life, it typically indicates a life-threatening disorder, such as sepsis, hemolytic disease of the neonate, Rh incompatibility, or ABO incompatibility. Physiological jaundice, which commonly occurs later, is a benign condition. Option 2 describes a normal neonate who doesn't require immediate assessment by the nurse. Option 3 describes a normal preterm neonate who doesn't require immediate assessment by the nurse. Although the neonate in option 4 is small for gestational age, he doesn't require immediate assessment by the nurse.

Pregnancy and the renal system

1. Frequency of urination increases in the first and third trimesters because of increased bladder sensitivity and pressure of the enlarging uterus on the bladder. 2. Decreased bladder tone may occur and is caused by an increase in progesterone and estrogen levels ; bladder capacity increases in response to increasing levels of progesterone. 3. Renal threshold for glucose may be reduced.

The neonate's respiratory function stabilizes about 24 hours after birth and is maintained by the effects of biochemical and environmental stimulation. What four physiologic conditions must be present in order for the neonate's respiratory functioning to proceed? 1. Functioning respiratory center, patent airway, intact nerves from the brain to the chest muscles, and adequate calories 2. Normothermia, patent airway, functioning respiratory center, and adequate calories 3. Closure of fetal shunts, patent airway, intact nerves from the brain to the chest muscles, and normothermia 4. Functioning respiratory center, patent airway, closure of fetal shunts, and intact nerves from the brain to chest muscles

1. Functioning respiratory center, patent airway, intact nerves from the brain to the chest muscles, and adequate calories Respiratory functioning requires a patent airway, a functioning respiratory center, intact nerves from the brain to the chest muscles, and adequate calories to supply energy for the labor of breathing. With birth comes functional closure of the fetal shunts. However, anatomic closure doesn't occur for up to 4 weeks. Clinically insignificant functional murmurs or transient cyanosis may result. Maintaining the neonate's body temperature is essential for successful extrauterine adaptation but isn't directly responsible for respiratory stabilization.

When assessing a client who has just delivered a neonate, the nurse finds that the fundus is boggy and deviated to the right. What should the nurse do? 1. Have the client void. 2. Assess the client's vital signs. 3. Evaluate lochia characteristics. 4. Massage the fundus.

1. Have the client void. Having the client void can determine whether the boggy, deviated fundus results from a full bladder — the most common cause of these fundal findings. Vital sign assessment is unnecessary unless the nurse suspects hemorrhage from delayed involution. In a client who doesn't have a full bladder, the nurse should evaluate lochia characteristics to detect possible hemorrhage. If the client has a full bladder, massaging the fundus won't stimulate uterine contractions (which aid uterine involution) or prevent uterine atony — a possible cause of hemorrhage.

When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis takes highest priority at this time? 1. Hypothermia related to heat loss 2. Impaired parenting related to the addition of a new family member 3. Risk for deficient fluid volume related to insensible fluid losses 4. Risk for infection related to transition to the extrauterine environment

1. Hypothermia related to heat loss The neonate's temperature should range from 97° to 97.7° F (36.1° to 36.5° C), and the respiratory rate should be less than 60 breaths/minute. (The respiratory rate increases as hypothermia develops.) Because this neonate's temperature is below normal and because cold stress can lead to respiratory distress and hypoglycemia, a diagnosis of Hypothermia related to heat loss takes highest priority. The other options may be appropriate but don't take precedence over hypothermia, which can be life-threatening.

A nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. Hypotonic 2. Precipitous 3. Hypertonic 4. Preterm labor

1. Hypotonic Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Hypertonic dystocia usually occurs during the latent phase of labor, and contractions are painful, frequent, and usually uncoordinated. Precipitous labor is labor that lasts in its entirety for 3 hours or less. Preterm labor is the onset of labor after 20 weeks of gestation and before the thirty-seventh week of gestation.

A nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester? 1. Increase in pulse rate 2. Increase in blood pressure 3. Frequent bowel elimination 4. Decrease in red blood cell production

1. Increase in pulse rate Between 14 and 20 weeks' gestation, the pulse rate increases about 10 to 15 beats/ min, which then persists to term. Options 2, 3, and 4 are incorrect. During pregnancy, the blood pressure usually is the same as the prepregnancy level, but then gradually decreases up to about 20 weeks of gestation. During the second trimester, systolic and diastolic pressures decrease by about 5 to 10 mm Hg. Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus. During pregnancy, there is an accelerated production of red blood cells.

The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)? 1. Intrauterine fetal death 2. Placenta accreta 3. Dysfunctional labor 4. Premature rupture of the membranes

1. Intrauterine fetal death Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the membranes aren't associated with DIC.

The nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy? 1. Iron deficiency anemia 2. Varicosities 3. Nausea and vomiting 4. Gestational diabetes

1. Iron deficiency anemia Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further. Varicosities are a complication of pregnancy more likely seen in women over age 35. An adolescent pregnancy doesn't increase the risk of nausea and vomiting or gestational diabetes.

As a postpartum client adapts to her maternal role, she progresses through several phases. During which phase does she begin to accept the neonate as a separate individual? 1. Letting-go phase 2. Taking-hold phase 3. Dependent phase 4. Taking-in phase

1. Letting-go phase Rubin identified three phases during which a woman adapts to the maternal role. During the taking-in (dependent) phase, which usually lasts 1 to 2 days after delivery, the client usually is exhausted and dependent on others, focusing on her own needs. During the taking-hold (dependent-independent) phase, which may last from 3 days to 8 weeks, the client vacillates between seeking nurturing and acceptance for herself and seeking to resume an independent role. During the letting-go (interdependent) phase, the client begins to accept the neonate as an individual who's separate from herself.

Interventions for chorioamnionitis

1. Monitor maternal vital signs and fetal heart rate. 2. Monitor for uterine tenderness, contractions, and fetal activity. 3. Monitor results of blood cultures. 4. Prepare for amniocentesis to obtain amniotic fluid for Gram stain and leukocyte count. 5. Administer antibiotics as prescribed after cultures are obtained. 6. Administer oxytocic medications as prescribed to increase uterine tone. 7. Prepare to obtain neonatal cultures after delivery.

Interventions throughout stage 1 of labor

1. Monitor maternal vital signs. 2. Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor. 3. Assess FHR before, during, and after a contraction, noting that the normal FHR is 120 to 160 beats/ min. 4. Monitor uterine contractions by palpation or tocodynamometer, determining frequency, duration, and intensity. 5. Assess status of cervical dilation and effacement. 6. Assess fetal station presentation and position by Leopold's maneuvers. 7. Assist with pelvic examination and prepare for a fern test.

A registered nurse (RN) calls in sick, leaving an RN and two nursing assistants to care for twelve postpartum clients. How should the RN on the postpartum floor respond to the staffing issue? 1. Notify the supervisor and request that another RN be assigned to the unit. 2. Notify the supervisor and request that another nursing assistant be assigned to the unit. 3. Plan ways to work efficiently with the two nursing assistants. 4. Inform the labor and delivery unit that the postpartum unit can't admit any clients.

1. Notify the supervisor and request that another RN be assigned to the unit. The RN can't safely administer care to 12 postpartum clients. Therefore, the RN should notify the supervisor of her staffing needs. Requesting another nursing assistant, working alone with the already assigned nursing assistants, and refusing further admissions don't fulfill the staffing unit's needs.

For a client who's moving into the active phase of labor, the nurse should include which of the following as the priority of care? 1. Offer support by reviewing the short-pant form of breathing. 2. Administer narcotic analgesia. 3. Allow the mother to walk around the unit. 4. Watch for rupture of the membranes.

1. Offer support by reviewing the short-pant form of breathing. By helping the client use the pant form of breathing, the nurse can help the client manage her contractions and reduce the need for opioids and other forms of pain relief, which can have an effect on fetal outcome. In the active phase, the mother most likely is too uncomfortable to walk around the unit. The nurse will observe for rupture of membranes and may administer opioid analgesia but these don't take priority.

Which of the following hormones is responsible for the let-down reflex? 1. Oxytocin 2. Prolactin 3. Estrogen 4. Progesterone

1. Oxytocin Oxytocin is responsible for milk let-down, the process that brings milk to the nipple. The other hormones mentioned contribute indirectly to the lactation process. Prolactin stimulates lactation. Estrogen stimulates development of the duct in the breast. Progesterone acts to increase the lobes, lobules, and alveoli of the breasts.

Because cervical effacement and dilation aren't progressing in a client in labor, the physician orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the client's fluid intake and output closely during oxytocin administration? 1. Oxytocin causes water intoxication. 2. Oxytocin causes excessive thirst. 3. Oxytocin is toxic to the kidneys. 4. Oxytocin has a diuretic effect.

1. Oxytocin causes water intoxication. The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake — not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

A nurse is reviewing the physician's prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which physician's prescription should the nurse question? 1. Perform a vaginal examination every shift. 2. Monitor maternal vital signs frequently. 3. Monitor fetal heart rate continuously. 4. Administer ampicillin 1 g as an intravenous piggyback every 6 hours.

1. Perform a vaginal examination every shift. Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to administer an antibiotic, monitor maternal vital signs, and monitor fetal heart rate.

A 22-year-old client with a history of drug abuse delivered a low-birth-weight neonate who is experiencing drug withdrawal. Which intervention is helpful for this neonate? 1. Place the isolette in a quiet area of the nursery. 2. Withhold medications until liver function improves. 3. Dress the neonate in loose-fitting clothing. 4. Place the isolette close to the nurse's station

1. Place the isolette in a quiet area of the nursery. The neonate experiencing drug withdrawal should be placed in a quiet area of the nursery to minimize stimuli; the nurses' station is typically not a quiet area. The neonate should be swaddled to prevent him from stimulating himself with movement. Medications should be administered as needed.

The nurse should teach a client to administer oxytocin (Syntocinon) nasal spray while: 1. sitting with her head vertical. 2. lying down with her head turned to the side. 3. sitting with her head tilted back. 4. lying down with her head tilted back.

1. sitting with her head vertical. Oxytocin nasal spray should be administered while the client is sitting with her head in a vertical position. A nasal preparation must not be administered with the client lying down or the head tilted back because this could cause aspiration.

Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which intervention by the nurse is most appropriate for this client? 1. Provide her with the information and teach her the skills she'll need to understand and cope during birth. 2. Provide her with written information about the birthing process. 3. Have a more experienced pregnant woman assist her. 4. Do nothing in hopes that she'll begin coping as the pregnancy progresses.

1. Provide her with the information and teach her the skills she'll need to understand and cope during birth. Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs.

A nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to: 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin (Pitocin) infusion closely.

1. Provide pain relief measures. Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.

A gravida 5 para 2 client delivers a 3,000-gram neonate at 38 weeks' gestation. During the assessment, the nurse notes that the neonate is hyperactive, jittery, and has a hyperactive rooting reflex combined with inconsolable crying. She also notes intrauterine growth retardation and suspect facial characteristics, such as short palebral fissures, flattened midfacies, short upturned nose, thin upper lip, and smooth philtrum. Based on these findings, what information should the nurse include in the mother's discharge plan? 1. Referral to an alcohol treatment counselor 2. Client education on isotretinoin (Retin-A) 3. Instructions on dietary sources of folic acid 4. Referral to cocaine treatment counselor

1. Referral to an alcohol treatment counselor The neonate is displaying signs of fetal alcohol syndrome, which occurs as a result of fetal alcohol exposure. The nurse should include referral to an alcohol treatment counselor as part of the mother's discharge plan. Teratogenic effects of isotretinoin include microtia, central nervous system defects, cleft lip and cleft palate, mental retardation, microphthalmia, and dysmorphic craniofacial features. Folic acid is recommended during pregnancy to prevent neural defects. Teratogenic effects of cocaine use during pregnancy include intrauterine growth retardation, microcephaly, cerebral infarction, and congenital malformations of the limbs, heart, genitourinary tract, and face.

Which of the following describes the term fetal position? 1. Relationship of the fetus's presenting part to the mother's pelvis 2. Fetal posture 3. Fetal head or breech at cervical os 4. Relationship of the fetal long axis to the mother's long axis

1. Relationship of the fetus's presenting part to the mother's pelvis Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis.

Actions to Take in the Event of Eclampsia

1. Remain with the client and call for help. 2. Ensure an open airway, turn the client on her side, and administer oxygen by face mask at 8 to 10 L/ min. 3. Monitor fetal heart rate patterns. 4. Administer medications to control the seizures as prescribed. 5. After the seizure, insert an oral airway and suction the client's mouth as needed. 6. Prepare for delivery of the fetus after stabilization of the client, if warranted. 7. Document occurrence, client's response, and outcome.

When caring for a client who has had a cesarean section, which action is not appropriate? 1. Removing the initial dressing for incision inspection 2. Monitoring pain status and providing necessary relief 3. Supporting self-esteem concerns about delivery 4. Assisting with parental newborn bonding

1. Removing the initial dressing for incision inspection Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate.

A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? 1. Report a heart rate greater than 120 beats/minute to the physician. 2. Take terbutaline every 4 hours, during waking hours only. 3. Call the physician if the fetus moves 10 times in an hour. 4. Increase activity daily if not fatigued.

1. Report a heart rate greater than 120 beats/minute to the physician. Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home.

To obtain a good monitor tracing on a client in labor, the mother lies in a supine position. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which of the following should be the nurse's first action? 1. Reposition the client to her left side. 2. Immediately take the client's blood pressure and summon the physician. 3. Start oxygen at 6 L via nasal cannula. 4. Increase the I.V. fluids to correct the client's dehydration.

1. Reposition the client to her left side. This client is hypotensive because of decreased blood flow through the aorta. By turning the client to her left side, the nurse removes the weight of the uterus from the aorta and increases the maternal blood flow. Taking blood pressure, summoning the physician, starting oxygen, and increasing I.V. fluids aren't necessary unless repositioning doesn't relieve the symptoms.

A neonate born at 28 weeks' gestation has been receiving 80% to 100% oxygen via mechanical ventilation for the past 2 weeks. She also has received multiple blood transfusions to treat anemia and has experienced several episodes of apnea. The nurse caring for her should anticipate which iatrogenic complication? 1. Retinopathy of prematurity 2. Transient tachypnea 3. Hyperbilirubinemia 4. Neonatal asphyxia

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

Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do? 1. Rewarm the neonate gradually. 2. Rewarm the neonate rapidly. 3. Observe the neonate at least hourly. 4. Notify the physician when the neonate's temperature is normal.

1. Rewarm the neonate gradually. A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.

The nurse is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? 1. Risk for deficient fluid volume related to hemorrhage 2. Risk for infection related to the type of delivery 3. Acute pain related to the type of incision 4. Urinary retention related to periurethral edema

1. Risk for deficient fluid volume related to hemorrhage Hemorrhage jeopardizes the client's oxygen supply — the first priority among human physiologic needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over diagnoses of Risk for infection, Acute pain, and Urinary retention.

Lochia normally progresses in which pattern? 1. Rubra, serosa, alba 2. Serosa, rubra, alba 3. Serosa, alba, rubra 4. Rubra, alba, serosa

1. Rubra, serosa, alba As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect.

A nurse is monitoring a client in labor who is receiving oxytocin (Pitocin) and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. (Number 1 is the first action, and number 6 is the last action.) ____ Reposition the client. ____ Stop the oxytocin infusion. ____ Perform a vaginal examination. ____ Check the client's blood pressure. ____ Administer oxygen by face mask at 8 to 10 L/ min. ____ Administer medication as prescribed to reduce uterine activity

1. Stop the oxytocin infusion. 2. Reposition the client. 3. Administer oxygen by face mask at 8 to 10 L/ min. 4. Perform a vaginal examination. 5. Check the client's blood pressure. 6. Administer medication as prescribed to reduce uterine activity If uterine hypertonicity occurs, the nurse would immediately intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer oxygen by face mask at 8 to 10 L/ min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal examination to check for a prolapsed cord. The nurse would check maternal blood pressure for the presence of hypertension or hypotension. The nurse stays with the client and contacts the physician as soon as possible (or asks another nurse to contact the physician) and then implements prescribed physician prescriptions, including the administration of medications to reduce uterine activity.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, a nurse places her in: 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1. Supine position with a wedge under the right hip Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's position or prone position is not practical for this type of abdominal surgery.

Which of the following is the most important aspect of nursing care in the postpartum period? 1. Supporting the mother's ability to successfully feed and care for her infant 2. Involving the family in the teaching 3. Providing group discussions on baby care 4. Monitoring the normal progression of lochia

1. Supporting the mother's ability to successfully feed and care for her infant Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Although family involvement in teaching, group discussions on baby care, and lochia monitoring are important aspects of care, the mother's ability to feed and care for her infant takes priority.

A pregnant client asks a nurse about the types of exercises that are allowable during pregnancy. The nurse should instruct the client that the safest exercise to engage in is which of the following? 1. Swimming 2. Scuba diving 3. Low-impact gymnastics 4. Bicycling with the legs in the air

1. Swimming Non- weight-bearing exercises are preferable to weight -bearing exercises during pregnancy. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the knee-chest position should be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non- weight-bearing exercises such as swimming are allowable.

A client delivered a healthy full-term baby girl 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action? 1. Tachycardia and hypotension 2. Gush of vaginal blood when she stands up 3. Blood stain 2" (5.1 cm) in diameter on the abdominal dressing 4. Complaints of abdominal pain

1. Tachycardia and hypotension A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartum woman who has been sitting and may suddenly gush out when she stands up. A 2" blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean section to feel pain at the incision site after her anesthesia has worn off.

A client delivered a healthy full-term baby girl 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action? 1. Tachycardia and hypotension 2. Gush of vaginal blood when she stands up 3. Blood stain 2" (5.1 cm) in diameter on the abdominal dressing 4. Complaints of abdominal pain

1. Tachycardia and hypotension A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartum woman who has been sitting and may suddenly gush out when she stands up. A 2" blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean section to feel pain at the incision site after her anesthesia has worn off.

A nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment signs noted in the newborn would alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. Presence of a barrel chest with acrocyanosis

1. Tachypnea and retractions A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is common in the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of respiratory distress syndrome. Silvestri, Linda Anne; Silvestri, Linda Anne (2010-10-12). Saunders Comprehensive Review for the NCLEX-RN® Examination (Kindle Locations 23087-23089). Elsevier Health Sciences. Kindle Edition.

The nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called? 1. Taking-in phase 2. Taking-hold phase 3. Letting-go phase 4. Taking-over phase

1. Taking-in phase The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by the responsibilities of caring for the neonate while still fatigued from delivery. Taking hold is the next phase, when the mother has rested and she can think and learn mothering skills with confidence. During the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the neonate, giving up the fantasy of delivery, and readjusting to the reality of caring for the neonate. Depression may occur during this stage.

A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first? 1. The time of membrane rupture 2. The frequency of contractions 3. The presence of back pain 4. The presence of bloody show

1. The time of membrane rupture First, the nurse should ask the client when her membranes ruptured because the risk of perinatal infection increases with the time elapsed between membrane rupture and the onset of contractions. After determining the time of membrane rupture, the nurse should ask about the frequency of contractions and find out whether the client has back pain or bloody show.

The nurse observes several interactions between a mother and her neonate son. Which of the following behaviors of the mother would the nurse identify as evidence of mother-infant attachment? 1. Talks and coos to her son. 2. Cuddles her son close to her. 3. Doesn't make eye contact with her son. 4. Requests that the nurse take the baby to the nursery for feedings. 5. Encourages the father to hold the baby. 6. Takes a nap when the baby is sleeping.

1. Talks and coos to her son. 2. Cuddles her son close to her. Talking, cooing, and cuddling with her son are positive signs that the mother is adapting to her new role as mother. Avoiding eye contact is a nonbonding behavior. Eye contact, touching, and speaking help establish attachment with a neonate. Feeding a neonate is an important role of a new mother and facilitates attachment. Encouraging the father to hold the neonate will facilitate attachment between the neonate and his father. Resting while the neonate is sleeping will conserve needed energy and allow the mother to be alert and awake when her infant is awake; however it isn't evidence of bonding.

Which of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor? 1. Tetanic contractions 2. Elevated blood pressure 3. Early decelerations of fetal heart rate 4. Water intoxication

1. Tetanic contractions Tetanic contractions are the most serious adverse effect associated with administering oxytocin. When tetanic contractions occur, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts of oxytocin have been administered, and this drug can also increase blood pressure. However, pulmonary edema and increased blood pressure aren't the most serious adverse effects. Early decelerations of fetal heart rate aren't associated with oxytocin administration.

A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1. The diet should include additional fluids. The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breast because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed.

What information should the nurse include when teaching postcircumcision care to parents of a neonate before discharge from the hospital? 1. The infant must void before being discharged home. 2. Petroleum jelly should be applied to the glans of the penis with each diaper change. 3. The infant can take tub baths while the circumcision heals. 4. Any blood noted on the front of the diaper should be reported. 5. The circumcision will require care for 2 to 4 days after discharge.

1. The infant must void before being discharged home. 2. Petroleum jelly should be applied to the glans of the penis with each diaper change. 5. The circumcision will require care for 2 to 4 days after discharge. It's necessary for the infant to void prior to discharge to ensure that the urethra isn't obstructed. A lubricating ointment is appropriate and is applied with each diaper change. Typically, the penis heals within 2 to 4 days, and circumcision care is needed for that period only. To prevent infection, avoid giving the infant tub baths until the circumcision is healed; sponge baths are appropriate. A small amount of bleeding is expected following a circumcision; parents should report only a large amount of bleeding.

For a client in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? 1. The membranes must rupture. 2. The fetus must be at 0 station. 3. The cervix must be dilated fully. 4. The client must receive anesthesia.

1. The membranes must rupture. Internal EFM can be applied only after the client's membranes have ruptured, when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. Although the client may receive anesthesia, it isn't required before application of an internal EFM device.

The nurse applies an external electronic fetal monitor (EFM) to assess a client's uterine contractions and evaluate the fetal heart rate (FHR). However, the client is uncomfortable and changes positions frequently, making FHR hard to assess. Consequently, the physician decides to switch to an internal EFM. Before internal monitoring can begin, which of the following must occur? 1. The membranes must rupture. 2. The client must receive anesthesia. 3. The cervix must be fully dilated. 4. The fetus must be at 0 station.

1. The membranes must rupture. Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm and when the presenting part is at least at -1 station. Anesthesia isn't required for internal EFM.

The nurse is performing a psychosocial assessment on a first-time mother and her neonate. Which behavior indicates a positive mother-neonate interaction? 1. The mother makes eye contact with the neonate. 2. The mother speaks to the neonate in an insistent tone. 3. The mother holds the neonate slightly away from her. 4. The mother pays more attention to the nurse than to the neonate.

1. The mother makes eye contact with the neonate. Behaviors that indicate a positive mother-neonate interaction include making eye contact with the neonate, talking to the neonate in a soothing tone, holding the neonate close, and paying more attention to the neonate than to the observer.

The nurse observes a late deceleration. It's characterized by and indicates which of the following? 1. U-shaped deceleration occurring after the first half of the contraction, indicating uteroplacental insufficiency 2. U-shaped deceleration occurring with the contraction, indicating cord compression 3. V-shaped deceleration occurring after the contraction, indicating uteroplacental insufficiency 4. Deep U-shaped deceleration occurring before the contraction, indicating head compression

1. U-shaped deceleration occurring after the first half of the contraction, indicating uteroplacental insufficiency A late deceleration is U-shaped and occurs after the first half of the contraction, indicating uteroplacental insufficiency. It's an ominous pattern and requires immediate action — such as administering oxygen, repositioning the mother, and increasing the I.V. infusion rate — to correct the problem. U- and V-shaped decelerations are variable decelerations occurring at unpredictable times during contractions and are related to umbilical cord compression. Deep U-shaped deceleration occurring before the contraction is early deceleration.

The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care? 1. Using a peri bottle to clean the perineum after each voiding or bowel movement 2. Cleaning the perineum from back to front after a bowel movement 3. Spraying water from peri bottle into the vagina 4. Changing perineal pads every 8 hours

1. Using a peri bottle to clean the perineum after each voiding or bowel movement Cleaning with a peri bottle (squirt or spray bottle) should be performed after each voiding or bowel movement. The perineum should be cleaned from front to back, to avoid contamination from the rectal area. To keep the perineum clean, perineal pads must be changed when they are soiled. Water from the peri bottle isn't sterile and should never be directed into the vagina.

A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/ day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides . Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

During the admission assessment of a female neonate, the nurse notes a large lump on the baby's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that: 1. a cephalohematoma doesn't cross the suture lines. 2. caput succedaneum occurs primarily with primigravidas. 3. a cephalohematoma occurs with a birth that required instrumentation. 4. caput succedaneum occurs primarily with a prolonged second stage of labor.

1. a cephalohematoma doesn't cross the suture lines. Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the baby's scalp during labor. Blood outside the vasculature in a neonate increases the possibility of jaundice as the neonate's body tries to reabsorb the blood. Caput succedaneum, which is simply soft tissue edema of the scalp, can occur in any labor and isn't limited to a prolonged second stage of labor.

The nurse visits a client at home on the 10th postpartum day. When assessing the client's uterus, the nurse expects to find: 1. a nonpalpable fundus in the abdomen. 2. a fundus palpable two fingerbreadths above the umbilicus. 3. a fundus palpable at the umbilicus. 4. a fundus palpable one fingerbreadth below the umbilicus.

1. a nonpalpable fundus in the abdomen. By the 10th day postpartum, the uterus should no longer be palpable. A fundus palpable above the umbilicus is expected during the third trimester. The fundus is palpable at or just above the umbilicus 1 hour after delivery.

A primigravid client is admitted to the labor and delivery area. Assessment reveals that she's in the early part of the first stage of labor. Her pain is likely to be most intense: 1. around the pelvic girdle. 2. around the pelvic girdle and in the upper legs. 3. around the pelvic girdle and at the perineum. 4. at the perineum.

1. around the pelvic girdle. During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, pain spreads to the upper legs and perineum. During the late part of the second stage and during childbirth, intense pain occurs at the perineum.

The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes a day. The first step the nurse should take to help the woman stop smoking is to: 1. assess the client's readiness to stop. 2. suggest that the client reduce the daily number of cigarettes smoked by one-half. 3. provide the client with the telephone number of a formal smoking cessation program. 4. help the client develop a plan to stop.

1. assess the client's readiness to stop. Before planning any intervention with a client who smokes, it's essential to determine whether or not the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation.

A client who delivered her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." The nurse should: 1. help the client break down large tasks into smaller ones. 2. encourage the client to work faster. 3. reassure the client that her feelings will soon pass. 4. help the client accept her new role.

1. help the client break down large tasks into smaller ones. If a client feels overwhelmed by the additional tasks brought on by her new role as a mother, the nurse should help her break down large tasks into smaller, more manageable ones. Encouraging her to work faster or reassuring her that her feelings will soon pass wouldn't address her needs. The nurse can't help the client accept her new role if the client feels overwhelmed.

A client with moderate pregnancy-induced hypertension (PIH) is a poor candidate for regional anesthesia during labor and delivery. If she were to receive this form of anesthesia, she might experience: 1. hypotension. 2. hypertension. 3. seizures. 4. polyuria.

1. hypotension. In a client with PIH, uteroplacental perfusion may be inadequate and gas exchange may be poor. Regional anesthesia increases the risk of hypotension resulting from sympathetic blockade, possibly causing fetal and maternal hypoxia. Hypertension, seizures, and polyuria aren't associated with regional anesthesia.

As part of the respiratory assessment, the nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because: 1. neonates are obligate nose breathers. 2. nasal patency is required for adequate feeding. 3. problems with nasal patency may cause flaring. 4. a deviated septum will interfere with breathing.

1. neonates are obligate nose breathers. Neonates are obligate nose breathers and have no ability to breathe through their mouths. Therefore, blocked nares contribute to respiratory distress in the neonate. Nasal patency is unnecessary for neonate feeding. Nasal flaring may indicate respiratory distress. A deviated septum doesn't cause significant breathing difficulties.

A pregnant client is diagnosed with group B streptococcus chorioamnionitis. The nurse should expect to administer which medication to prevent fetal transmission? 1. penicillin G potassium (Pfizerpen) I.V. to the client 2. amoxicillin (Amoxil) P.O. to the client 3. ceftriaxone (Rocephin) I.M. to the neonate immediately after delivery 4. methylprednisolone (Solu-Medrol) I.V. to the client

1. penicillin G potassium (Pfizerpen) I.V. to the client Administering penicillin G potassium I.V. before delivery will prevent fetal transmission of group B streptococcus infection. Amoxicillin P.O. isn't affective against chorioamnionitis caused by group B streptococcus. Treatment with penicillin G potassium should begin before delivery to prevent fetal transmission. Steroids, such as methylprednisolone, aren't bacteriocidal.

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be: 1. red and moderate. 2. continuous with red clots. 3. brown and scant. 4. thin and white.

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

A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer: 1. ritodrine (Yutopar). 2. bromocriptine (Parlodel). 3. magnesium sulfate. 4. betamethasone (Celestone).

1. ritodrine (Yutopar). Ritodrine reduces frequency and intensity of uterine contractions by stimulating B2 receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia — a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother).

A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-feeding within 30 minutes of the neonate's birth because: 1. the neonate will be responsive and eager to suck at this time. 2. breast-feeding will inhibit prolactin production. 3. her breasts will be firm and filled with colostrum at this time. 4. breast-feeding will help the neonate fall asleep.

1. the neonate will be responsive and eager to suck at this time. During the first 30 minutes or so after birth, the healthy, full-term neonate is highly responsive and has a strong desire to suck. Many neonates breast-feed shortly after delivery; all make licking or nuzzling motions, helping to stimulate the mother's prolactin production and enhance maternal-neonate bonding. Also, the client's breasts may be soft and easily manipulated at this time, promoting proper attachment of the neonate. Although the breasts contain colostrum at this time, they aren't firm. Typically, the neonate falls asleep 2 to 3 hours after birth.

The nurse should tell new mothers who are breast-feeding that breast milk is produced when: 1. the placenta is delivered, causing the secretion of prolactin. 2. the newborn begins to suckle and stimulates the anterior pituitary to produce prolactin. 3. oxytocin is released from the posterior pituitary gland. 4. relaxin is released from the ovary.

1. the placenta is delivered, causing the secretion of prolactin. Delivery of the placenta causes the secretion of prolactin, which in turn produces breast milk. Thus, retained placental fragments can interfere with the production of milk. When the neonate sucks at the breast, the hypothalamus stimulates the production of prolactin-releasing factor, which further stimulates active production of prolactin to maintain milk production; sucking, however, doesn't initiate prolactin secretion. Oxytocin acts to constrict milk glands and push milk forward in the ducts that lead to the nipple. The role of relaxin is unknown.

During the fourth stage of labor, the client should be assessed carefully for: 1. uterine atony. 2. complete cervical dilation. 3. placental expulsion. 4. umbilical cord prolapse.

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

A client, age 19, goes into labor at 40 weeks' gestation. When assessing the fetal monitor strip, the nurse sees that the fetal heart rate (FHR) has decreased to 60 beats/minute and that the waveforms sometimes resemble a V and begin and end abruptly. The nurse should interpret this pattern as: 1. variable decelerations. 2. decreased short-term variability. 3. increased long-term variability. 4. early decelerations.

1. variable decelerations. On a fetal monitor strip, variable decelerations are characterized by an FHR that commonly decreases to 60 beats/minute; waveform shapes that vary and may resemble the letter U, V, or W; and deceleration waveforms with an abrupt onset and recovery. Decreased short-term variability manifests as fewer than 2 to 3 beats/amplitude of the baseline FHR. Increased long-term variability manifests as more than 5 to 20 beats/minute of the baseline FHR in rhythmic fluctuation. Early decelerations are seen as the descent, peak, and recovery of the deceleration waveform that mirrors the contraction waveform.

A full-term neonate is diagnosed with hydrocephalus. Nursing assessment is most likely to reveal: 1. wide or bulging fontanels. 2. a decreased occipitofrontal circumference. 3. upward-slanting eyes. 4. heightened alertness.

1. wide or bulging fontanels. Hydrocephalus typically causes an enlarged head with wide or bulging fontanels, an excessive diameter (increased occipitofrontal diameter), a shiny scalp with prominent veins, separation of the suture lines, and downward-slanting eyes. Other findings in hydrocephalus include bradycardia, apneic episodes, vomiting, irritability, excessive crying, and reduced alertness.

The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term neonate. Which needle should the nurse use? 1. 25G, 1" needle 2. 25G, 5/8" needle 3. 22G, 1" needle 4. 22G, 5/8" needle

2. 25G, 5/8" needle Routinely, the nurse uses a 25G, 5/8" needle to administer prophylactic vitamin K to a neonate because this needle allows the medication to reach the muscle without causing excessive pain or trauma. A 1" needle is appropriate for an adult, not a neonate. The nurse uses a 22G needle only when administering thick medications such as penicillin.

Which of the following is the approximate time that the blastocyst spends traveling to the uterus for implantation? 1. 2 days 2. 7 days 3. 10 days 4. 14 weeks

2. 7 days The blastocyst takes approximately 1 week to travel to the uterus for implantation. The other options are incorrect.

A pregnant client calls a clinic and tells a nurse that she is experiencing leg cramps that awaken her at night . To provide relief from the leg cramps, the nurse tells the client the following: 1. "Bend your foot toward your body while flexing the knee when the cramps occur." 2. "Bend your foot toward your body while extending the knee when the cramps occur." 3. "Point your foot away from your body while flexing the knee when the cramps occur." 4. "Point your foot away from your body while extending the knee when the cramps occur."

2. "Bend your foot toward your body while extending the knee when the cramps occur." Leg cramps occur when the pregnant client stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting , and stops the cramping. Options 1, 3, and 4 are not measures that provide relief from leg cramps.

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response? 1. "I can see you're upset. Why don't we discuss this with you at a later time when you're feeling better." 2. "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." 3. "Let me check with your physician and get you something that will help you relax." 4. "Pregnancy should be avoided until all of your testing is normal."

2. "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 12 months by an experienced health care provider. Discussing this situation at a later time, or checking with the physician to give the client something to relax, do nothing to address the client's immediate concerns. Advising the client to wait until all tests are normal is vague and provides the client with little information.

The nurse demonstrates infant bathing to a primiparous client. Which statement by the client indicates a lack of understanding? 1. "I'm going to bathe the baby in the kitchen because it's nice and warm there." 2. "I have all kinds of pretty, scented soaps and lotions to bathe the baby with." 3. "I'll sponge-bathe the baby until the cord area heals." 4. "I'll wash the baby's eyes and face first."

2. "I have all kinds of pretty, scented soaps and lotions to bathe the baby with." Scented and medicated soaps and lotions aren't recommended for infants because they may alter the skin pH, making the skin less able to fight infection. Bathing the infant in a warm room, sponge-bathing the infant until the cord area heals, and washing the eyes and face first are appropriate activities and indicate an understanding of teaching regarding infant bathing.

A nurse in a health care clinic is instructing a pregnant client how to perform " kick counts." Which statement by the client indicates a need for further instructions? 1. "I will record the number of movements or kicks." 2. "I need to lie flat on my back to perform the procedure." 3. "If I count fewer than 10 kicks in a 12-hour period, I need to contact the physician." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

2. "I need to lie flat on my back to perform the procedure." The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure , can cause discomfort, and presents a risk of vena caval (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the physician or nurse -midwife if there are fewer than 10 kicks in a 12-hour period or as instructed by the physician or nurse -midwife.

The nurse is teaching a client who's 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling this client's blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says: 1. "I won't use insulin if I'm sick." 2. "I need to use insulin each day." 3. "If I give myself an insulin injection, I don't need to watch what I eat." 4. "I'll monitor my blood glucose levels twice a week."

2. "I need to use insulin each day." When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid periods of hypoglycemia and hyperglycemia when taking insulin. Fasting, postprandial, and bedtime blood glucose levels need to be checked daily.

When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breast-feeding success? 1. "It's contraindicated for you to breast-feed following this type of surgery." 2. "I support your commitment; however, you may have to supplement each feeding with formula." 3. "You should check with your surgeon to determine whether breast-feeding would be possible." 4. "You should be able to breast-feed without difficulty."

2. "I support your commitment; however, you may have to supplement each feeding with formula." Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breast-feeding after surgery is possible. Still, it's good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother's ability to meet all of her baby's nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client's psychological adaptation to mothering may be dependent on how successfully she breast-feeds.

A mother is concerned that her neonate son, who was delivered without complications at 38 weeks, isn't eating enough and will lose too much weight. The mother states, "He only breast-feeds for about 3 minutes on one side." Which of the following instructions should the nurse provide to this mother? 1. "Don't worry. When he's hungry, he'll eat. You'll see; it will be fine." 2. "I understand your concern, but don't worry. He has stored nutrients before birth just for this reason." 3. "It's important that he doesn't lose too much weight. We should start him on formula after each feeding." 4. "I am concerned, too, and will notify the pediatrician immediately."

2. "I understand your concern, but don't worry. He has stored nutrients before birth just for this reason." Neonates who are born at term without complications have stores of brown fat located on the vital organs. These stores will provide the neonate with the needed calories until lactation is well established. Cold, stress, and transitional neonatal problems may use up the stores of brown fat. Telling the client not to worry and saying things will be fine ignores the mother's concerns. Starting the neonate on formula and notifying the physician are inappropriate at this time.

A client who's 5 weeks pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by: 1. 5 to 8 weeks' gestation. 2. 9 to 12 weeks' gestation. 3. 14 to 17 weeks' gestation. 4. 18 to 22 weeks' gestation.

2. 9 to 12 weeks' gestation. Nausea, vomiting, urinary frequency, and urinary urgency normally subside between 9 and 12 weeks' gestation.

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instructions? 1. "I will watch for the evidence of the passage of tissue." 2. "I will maintain strict bedrest throughout the remainder of the pregnancy." 3. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." 4. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."

2. "I will maintain strict bedrest throughout the remainder of the pregnancy." Strict bedrest throughout the remainder of the pregnancy is not required for a threatened abortion. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the physician or other health care provider. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client also should watch for the evidence of the passage of tissue.

The nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to avoid breast engorgement? 1. "I'll apply warm, moist compresses to my breasts." 2. "I'll breast-feed whenever the baby is hungry." 3. "I'll use an electric breast pump." 4. "I'll wear a bra 24 hours a day."

2. "I'll breast-feed whenever the baby is hungry." Frequent breast-feeding keeps the breasts relatively empty and increases circulation, thereby helping to remove fluid that may lead to engorgement. Applying warm compresses to the breasts stimulates the let-down reflex, filling the breasts and increasing engorgement. An electric breast pump usually isn't used if the neonate can breast-feed frequently. Although a bra supports the breasts, it can't prevent engorgement.

When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her? 1. "I'll report increased frequency of urination." 2. "If I have blurred or double vision, I should call the clinic immediately." 3. "If I feel tired after resting, I should report it immediately." 4. "Nausea should be reported immediately."

2. "If I have blurred or double vision, I should call the clinic immediately." Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy.

After delivering her second baby, the client tells the nurse that she wants to breast-feed this baby. She indicates that she was unsuccessful at breast-feeding her first child and that she bottle-fed after 3 days of trying to nurse. Which of the following responses would best support this client's breast-feeding efforts? 1. "I'll make sure that you're seen by the lactation consultant before you're discharged." 2. "It's important to room-in with your newborn so that you can respond to her nursing cues." 3. "Don't worry, every baby is different, and I'm sure that you'll be successful this time." 4. "Breast-feeding is possible but you must be committed to it."

2. "It's important to room-in with your newborn so that you can respond to her nursing cues." One way to help support this client's wishes to breast-feed is to instruct her to room-in with her baby so she can respond to the baby's cues. Sending the infant to the nursery lessens the mother's ability to learn her baby's breast-feeding cues. The other options don't support the client's need for guidance.

The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? 1. "The client demonstrates the ability to care for the newborn completely by time of discharge." 2. "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." 3. "The client demonstrates an understanding of her physical needs related to labor and delivery." 4. "The client demonstrates an understanding of the newborn's physical needs related to labor and delivery."

2. "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." Discussing the childbirth experience helps the client acknowledge and understand what happened during this event. The nurse should give the client a chance to ask questions about the event and seek clarification, if needed. After the client discusses the event, she may be able to shift the focus away from herself and begin the tasks that will help her assume the maternal role. The nurse must determine the client's understanding of her physical needs and those of her infant after teaching and demonstrating care techniques; discussing the childbirth experience won't help her to meet these needs.

A pregnant client in her second trimester visits the health care practitioner for a regular prenatal checkup. During the assessment, the nurse weighs the client, then compares her current and previous weights. During the second trimester, how much weight should the client gain per week? 1. 0.5 lb (0.23 kg) 2. 1 lb (0.45 kg) 3. 1.5 lb (0.68 kg) 4. 2 lb (.91 kg)

2. 1 lb (0.45 kg) During the second and third trimesters, weight gain should average about 1 lb per week in a client with a single fetus. A woman with a multiple-fetus pregnancy should gain about 1.5 lb per week, on average, during the second half of pregnancy.

The nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones? 1. 7 weeks 2. 11 weeks 3. 17 weeks 4. 21 weeks

2. 11 weeks Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation.

During a prenatal visit, the nurse measures a client's fundal height at 19 cm. This measurement indicates that the fetus has reached approximately which gestational age? 1. 12 weeks 2. 19 weeks 3. 24 weeks 4. 28 weeks

2. 19 weeks The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.

A 12-hour-old neonate has a continuous Grade II cardiac murmur with no thrill. The splitting of S2 that was heard with inspiration immediately after birth is no longer present. The neonate's heart rate is 150 beats/minute. Based on these assessment findings, how should the neonate be transported to the parents? 1. The hospital volunteer assigned to the nursery should transport the neonate in an isolette. 2. A nursing assistant should transport the neonate in a bassinet. 3. The licensed practical nurse (LPN) should transport the neonate in a bassinet with an oxygen hood to administer oxygen during transport. 4. A registered nurse (RN) should transport the neonate in a warmed isolette with a cardiac monitor and oxygen saturation monitor.

2. A nursing assistant should transport the neonate in a bassinet. A splitting of S2 with inspiration commonly occurs during the first few hours of life. If it continues, it's most likely caused by a congenital heart defect. Murmurs commonly occur in the neonate and normal heart rate ranges from 120 to 160 beats/minute. The neonate in this scenario has a heart rate of 150 beats/minute, which falls within the normal range. Because these assessment findings are normal for a 12-hour-old neonate, the nursing assistant can safely transport the neonate in a bassinet to the parents. Transporting the neonate in an isolette isn't necessary. The neonate doesn't require an LPN or RN for transport.

A nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with fetal alcohol syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz 4. Head circumference appropriate for gestational age

2. Abnormal palmar creases Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy . Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant.

The nurse is assessing a pregnant woman. Which signs or symptoms indicate a hydatidiform mole? 1. Rapid fetal heart tones 2. Abnormally high human chorionic gonadotropin (HCG) levels 3. Slow uterine growth 4. Lack of symptoms of pregnancy

2. Abnormally high human chorionic gonadotropin (HCG) levels In a pregnant woman with a hydatidiform mole, the trophoblast villi proliferate and then degenerate. Proliferating trophoblast cells produce abnormally high HCG levels. No fetal heart tones are heard because there is no viable fetus. Because there is rapid proliferation of the trophoblast cells, the uterus grows fast and is larger than expected for a given gestational date. Because of the greatly elevated HCG levels, a woman with hydatidiform mole often has marked nausea and vomiting.

The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rho(D)-negative and her baby is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? 1. Administration of Rho(D) immune globulin I.M. to the baby within 72 hours 2. Administration of Rho(D) immune globulin I.M. to the mother within 72 hours 3. Injection of Rho(D) immune globulin to the mother during her 6 week follow-up visit 4. Administration of Rho(D) immune globulin I.M. to the mother within 3 months

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

Parents of an infant infected with human immunodeficiency virus (HIV) tell the nurse that they aren't going to inform the daycare providers about their son's infection. How should the nurse respond to the parents' plan? 1. Teach the parents how to wear a facial mask and gown during diaper changes. 2. Agree that the parents have the legal right to confidentiality. 3. Tell them there is a greater risk of HIV transmission to other infants in the daycare setting. 4. Notify the director of the daycare of the infant's HIV status.

2. Agree that the parents have the legal right to confidentiality. Parents have the legal right to decide whether they will inform daycare providers of the infant's HIV status. If they decide not to inform a facility, the nurse can't breach client confidentiality and notify the daycare director herself. Standard precautions should be followed in the daycare facility for all children. Gloves should be worn during diaper changes. There isn't an increased risk of HIV transmission among infants in the daycare setting.

Which of the following physiologic changes during labor makes it necessary for the nurse to assess blood pressure frequently? 1. Blood pressure decreases as a sign of maternal pain. 2. Alterations in cardiovascular function affect the fetus. 3. Blood pressure decreases at the peak of each contraction. 4. Decreased blood pressure is the first sign of preeclampsia.

2. Alterations in cardiovascular function affect the fetus. During contractions, blood pressure increases and blood flow to the intervillous spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently assess the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, the maternal blood pressure usually increases, rather than decreases. Preeclampsia causes the blood pressure to increase — not decrease.

A nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. The nurse tells the client that: 1. Strict bed rest is required after the procedure. 2. An informed consent needs to be signed before the procedure. 3. Hospitalization is necessary for 24 hours after the procedure. 4. A fever is expected after the procedure because of the trauma to the abdomen.

2. An informed consent needs to be signed before the procedure. Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in a physician's private office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.

The nurse brings a new mother her baby for the first time approximately 1 hour after the baby's birth. After checking the identification, the nurse hands the baby to the mother. Within a few minutes, the mother begins to undress her baby. Which of the following should the nurse do? 1. Call the pediatrician and report the behavior. 2. Anticipate and support the behavior as a normal part of bonding. 3. Encourage the mother to rewrap the baby because the room is cold. 4. Take the baby back to the nursery and recheck the baby's temperature.

2. Anticipate and support the behavior as a normal part of bonding. The behavior demonstrated by the mother is normal during the "taking-hold" process. The nurse should anticipate and support this behavior. Because this is normal behavior for establishing a relationship, it doesn't need to be reported. It's highly doubtful that the baby would become chilled during this brief time of being undressed. Therefore, rewrapping the baby and taking her back to the nursery to check her temperature isn't necessary.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? 1. Ask the client to turn on her side. 2. Ask the client to urinate and empty her bladder. 3. Massage the fundus gently before determining the level of the fundus. 4. Ask the client to lie flat on her back with the knees and legs flat and straight.

2. Ask the client to urinate and empty her bladder. Before starting the fundal assessment, the nurse should ask the client to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the client to lie flat on her back with the knees flexed. Massaging the fundus is inappropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm.

A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, the initial nursing assessment is which of the following? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

2. Assess the baseline fetal heart rate. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

A client at 35 weeks' gestation complains of severe abdominal pain and passing clots. The client's vital signs are blood pressure 150/100 mm Hg, heart rate 95 beats/minute, respiratory rate 25 breaths/minute, and fetal heart tones 160 beats/minute. The admitting nurse must determine the cause of the bleeding and respond appropriately to this emergency. Which of the following should the nurse do first? 1. Examine the vagina to determine whether her client is in labor. 2. Assess the location and consistency of the uterus. 3. Perform an ultrasound to determine placental placement. 4. Prepare for immediate delivery.

2. Assess the location and consistency of the uterus. The nurse must determine whether placenta previa or abruptio placentae is the problem. (Fifty percent of all clients with hypertension will develop abruptio placenta.) In this case, the presenting symptoms are highly suggestive of an abruption, so the nurse must determine the level of the uterus and mark that level on the client's abdomen. She must also check the consistency of the uterus; a uterus that is filling with blood because the placenta has detached early is rigid. Bleeding from a placental previa is usually painless. A vaginal examination is contraindicated in the presence of bleeding. Most nurses haven't been taught how to perform an ultrasound. If the client has a placental abruption, birth will most likely be by cesarean section.

A client is progressing through the first stage of labor. Which finding signals the beginning of the second stage of labor? 1. Passage of the mucus plug 2. Bearing-down reflex 3. Change in uterine shape 4. Gush of dark blood

2. Bearing-down reflex The second stage of labor is heralded by a bearing-down reflex with each contraction, increased bloody show, severe rectal pressure, and rupture of the membranes (if this hasn't already occurred). Passage of the mucus plug typically occurs during the latent phase of the first stage of labor. A change in uterine shape and a gush of dark blood occur during the placental separation phase of the third stage of labor.

The nurse is developing a teaching plan for a client who's 2 months pregnant. The nurse should tell the client that she can expect to feel the fetus move at which time? 1. Between 10 and 12 weeks' gestation 2. Between 16 and 20 weeks' gestation 3. Between 21 and 23 weeks' gestation 4. Between 24 and 26 weeks' gestation

2. Between 16 and 20 weeks' gestation A pregnant woman can usually detect fetal movements (quickening) between 16 and 20 weeks' gestation. Before 16 weeks, the fetus isn't developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

When providing health teaching to a primigravid client, the nurse tells the client that she's likely to first experience Braxton Hicks contractions. When do these contractions typically begin? 1. Between 18 and 22 weeks' gestation 2. Between 23 and 27 weeks' gestation 3. Between 28 and 31 weeks' gestation 4. Between 32 and 35 weeks' gestation

2. Between 23 and 27 weeks' gestation Braxton Hicks contractions typically begin between 23 and 27 weeks' gestation. The fetal heartbeat typically can be heard and fetal rebound is possible between 18 and 22 weeks. The fetal outline becomes palpable and the fetus is highly mobile between 28 and 31 weeks. Braxton Hicks contractions increase in frequency and intensity between 32 and 35 weeks.

The nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect? 1. Absent pedal pulses 2. Bilateral dependent edema 3. Sluggish capillary refill 4. Unilateral calf enlargement

2. Bilateral dependent edema As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs — an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.

A client is admitted to the labor and delivery area. How can the nurse most effectively determine the duration of the client's contractions? 1. By timing the period between one contraction and the beginning of the next contraction 2. By timing the period from the onset of uterine tightening to uterine relaxation 3. By timing the period from the increment (building-up) phase to the acme (peak) phase 4. By timing the period from the acme (peak) phase to the decrement (letting-down) phase

2. By timing the period from the onset of uterine tightening to uterine relaxation To determine the duration of contractions, the nurse should time the period from the onset of uterine tightening to uterine relaxation. Timing the period between one contraction and the beginning of the next contraction helps determine the frequency of contractions. Timing the period from the increment to the acme or from the acme to the decrement supplies only partial information about contractions.

A client is admitted to the labor and delivery area. The nurse-midwife checks for fetal descent, flexion, internal rotation, extension, external rotation, and expulsion. What do these terms describe? 1. Phases of the first stage of labor 2. Cardinal movements of labor 3. Factors affecting labor 4. Factors that determine fetal position

2. Cardinal movements of labor Cardinal movements of labor refer to the typical sequence of positions assumed by the fetus during labor and delivery. These positions are most commonly called descent, flexion, internal rotation, extension, external rotation, and expulsion. Phases of the first stage of labor include the latent, active, and transitional phases. Factors affecting labor include the passenger, passageway, powers, placental position and function, and psychological response. Factors that determine fetal position include the landmark of the fetal presenting part, whether the landmark faces the left or right side of the maternal pelvis, and whether the landmark faces the front, back, or side of the maternal pelvis.

The nurse is instructing a client about breast-feeding. Which instructions should she include to help prevent the mother from developing mastitis? 1. Wash the nipples with soap and water. 2. Change the breast pads frequently. 3. Expose the nipples to air for part of each day. 4. Wash hands before handling the breast and breast-feeding. 5. Make sure that the baby grasps the nipple only. 6. Release the baby's grasp on the nipple before removing the baby from the breast.

2. Change the breast pads frequently. 3. Expose the nipples to air for part of each day. 4. Wash hands before handling the breast and breast-feeding. 6. Release the baby's grasp on the nipple before removing the baby from the breast. Because mastitis is an infection frequently associated with a break in the skin surface of the nipple, measures to prevent cracked and fissured nipples help prevent mastitis. Changing breast pads frequently and exposing the nipples to air for part of the day help keep the nipples dry and prevent irritation. Washing hands before handling the breast reduces the chance of accidentally introducing organisms into the breast. Releasing the baby's grasp on the nipple before removing the baby from the breast also reduces the chance of irritation. Nipples should be washed with water only; soap tends to remove the natural oils and increases the chance of cracking. The baby should grasp both the nipple and areola.

A neonate is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the neonate under the radiant heater, the nurse should take which action? 1. Perform a full neonatal assessment 2. Check the neonate's blood glucose level 3. Review the pregnancy and delivery history 4. Call the pediatrician to report findings

2. Check the neonate's blood glucose level Maintenance of a blood sugar level at 50 mg or greater is required to ensure enough glucose for the brain and metabolism. Neonates who are cold stressed are at high risk for low blood sugars, a condition that requires immediate intervention to prevent damage to the neurologic system. Performing a full assessment, reviewing the pregnancy and delivery history, and contacting the pediatrician are done after the blood glucose level is obtained.

Certain drugs used during the postpartum period may affect blood pressure. Which drug would decrease a postpartum client's blood pressure? 1. Oxytocin (Syntocinon) 2. Codeine phosphate 3. Ergonovine (Ergotrate Maleate) 4. Methylergonovine (Methergine)

2. Codeine phosphate Codeine phosphate, given to relieve postpartum pain, may cause a decrease in blood pressure. Oxytocin reduces postpartum bleeding after expulsion of the placenta and may cause hypertension. Ergonovine and methylergonovine prevent or treat postpartum hemorrhage from uterine atony or subinvolution and may cause an increase in blood pressure.

A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time? 1. Breathing techniques during labor 2. Common discomforts of pregnancy 3. Infant care responsibilities 4. Neonatal nutrition

2. Common discomforts of pregnancy During the first trimester, a pregnant client is most concerned with her own needs. Because she's likely to experience discomforts of pregnancy, such as morning sickness, fatigue, and urinary frequency, the nurse should teach her how to relieve these discomforts. The nurse should teach labor breathing techniques during the second half of the pregnancy, when the client is most strongly motivated to learn them. The postpartum period is the best time to teach about infant care responsibilities and neonatal nutrition if the client didn't attend prenatal classes. Otherwise, infant care is taught during the third trimester and reinforced in the postpartum period.

The nurse-midwife determines that a client is in the second stage of labor and may start pushing. What marks the beginning of the second stage, and what marks the end? 1. Cervical dilation of 7 to 8 cm; complete cervical dilation 2. Complete cervical dilation; delivery of the neonate 3. Cervical dilation of 7 to 8 cm; delivery of the placenta 4. Complete cervical dilation; delivery of the placenta

2. Complete cervical dilation; delivery of the neonate The second stage of labor begins with complete cervical dilation and ends with delivery of the neonate.

A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, the nurse's highest priority should be to: 1. Turn on the apnea and cardiorespiratory monitors. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5 ° C (97.6 ° F).

2. Connect the resuscitation bag to the oxygen outlet. The highest priority on admission to the nursery for a newborn with a low Apgar score is the airway, which would involve preparing respiratory resuscitation equipment and oxygen. The remaining options are also important, although they are of lower priority. The newborn would be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer would provide an external heat source, which is necessary to prevent further respiratory distress.

The nurse is caring for a client who's on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy? 1. Hypoglycemia 2. Crackles 3. Bradycardia 4. Hyperkalemia

2. Crackles Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia.

A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic? 1. Labor techniques 2. Danger signs during pregnancy 3. Signs and symptoms of pregnancy 4. Tests to evaluate for high-risk pregnancy

2. Danger signs during pregnancy No matter how far the client's pregnancy has progressed by the time of her first prenatal visit, the nurse should teach about danger signs during pregnancy so the client can identify and report them early, helping to avoid complications. The nurse should discuss other topics just before they're expected to occur. For example, the nurse should teach about labor techniques near the end of pregnancy; signs and symptoms of pregnancy, shortly before they're anticipated, based on the number of weeks' gestation; and any tests, a few weeks before they're scheduled.

A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client? 1. Deficient knowledge (pregnancy) 2. Deficient fluid volume 3. Anticipatory grieving 4. Acute pain

2. Deficient fluid volume If bleeding and clots are excessive, this client may become hypovolemic, leading to a diagnosis of Deficient fluid volume. Although the other diagnoses are applicable to this client, they aren't the primary diagnosis.

A client who's 24 weeks pregnant has sickle cell anemia. When preparing the care plan, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy? 1. Sedative use 2. Dehydration 3. Hypertension 4. Tachycardia

2. Dehydration Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren't known to precipitate a sickle cell crisis.

While assessing a 2-hour-old neonate, the nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform initially? 1. Activate the code emergency response system. 2. Do nothing — acrocyanosis is normal in the neonate. 3. Take the neonate's temperature immediately according to hospital policy. 4. Notify the physician that a cardiac consult is needed.

2. Do nothing — acrocyanosis is normal in the neonate. Acrocyanosis, or bluish hands and feet in the neonate, is a normal finding and shouldn't last more than 24 hours after birth. The other choices are inappropriate.

The nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that coincide with the client's contractions. What term does the nurse use to document this finding? 1. Prolonged decelerations 2. Early decelerations 3. Late decelerations 4. Accelerations

2. Early decelerations A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they're called early decelerations. Early decelerations result from head compression during normal labor and don't indicate fetal distress. Prolonged decelerations, also known as reflex bradycardia, are decreases in fetal heart rate that last 60 to 90 seconds. These occur in response to sudden vagal stimulation. Prolonged decelerations may indicate fetal distress. Late decelerations start after the beginning of a contraction. The lowest point of a late deceleration occurs after the contraction ends. Accelerations are transient rises in the fetal heart rate that are normally caused by fetal movements and uterine contractions.

A client gives birth to a stillborn infant at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful? 1. Be selective in providing the information that the client seeks. 2. Encourage the client to see, touch, and hold the dead infant. 3. Provide information about possible causes of the stillbirth only if the client requests it. 4. Let the child's father decide what information the client receives.

2. Encourage the client to see, touch, and hold the dead infant. When caring for a client who has suffered perinatal loss, the nurse should provide an opportunity for her to bond with the dead child and allow the child to become part of the family unit. Parents who aren't given such a chance may experience fantasies about the child, which may be worse than the reality. If the child has gross deformities, the nurse should prepare the client for these. If the client doesn't ask about her child, the nurse should encourage her to do so and provide any information she seems ready to hear. The client needs a full explanation of all factors related to the experience so she can grieve appropriately. Letting the child's father decide which information the client receives is inappropriate.

A postpartum client is diagnosed with cystitis. The nurse plans for which priority nursing intervention in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2. Encouraging fluid intake Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

The nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should include which nursing diagnosis in the client's care plan? 1. Anxiety related to the facility environment 2. Fear related to a potentially difficult childbirth 3. Compromised family coping related to hospitalization 4. Acute pain related to labor contractions

2. Fear related to a potentially difficult childbirth A client's ability to cope during labor and delivery may be hampered by fear of a painful or difficult childbirth, fear of loss of control or self-esteem during childbirth, or fear of fetal death. A previous negative experience may increase these fears. Therefore, Fear related to a potentially difficult childbirth is the most appropriate nursing diagnosis. The client's anxiety stems from her past history of a long labor, not from being in the facility; therefore a diagnosis of Anxiety related to the facility environment isn't warranted. There is no evidence of compromised family coping related to hospitalization. Although acute pain related to labor contractions may be a problem, this isn't mentioned in the question.

A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? 1. Hemoglobin of 11 g/ dL 2. Fetal heart rate of 180 beats/ min 3. Maternal pulse rate of 85 beats/ min 4. White blood cell count of 12,000/mm3

2. Fetal heart rate of 180 beats/ min Normal fetal heart rate is 120 to 160 beats/ min. Fetal heart rate of 180 beats/ min could indicate fetal distress and would warrant immediate notification of the physician. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000/mm3 (up to 18,000/mm3). During the immediate postpartum period , white blood cell count may be 25,000 to 30,000/mm3 because of increased leukocytosis that occurs during delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/ dL because of the hemodilution caused by an increase in plasma volume during pregnancy . The maternal pulse rate during pregnancy increases 10 to 15 beats /min over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.

A client with Rh isoimmunization delivers a neonate with an enlarged heart and severe, generalized edema. Which nursing diagnosis is most appropriate for this client? 1. Ineffective denial related to a socially unacceptable infection 2. Impaired parenting related to the neonate's transfer to the intensive care unit 3. Deficient fluid volume related to severe edema 4. Fear related to removal and loss of the neonate by statute

2. Impaired parenting related to the neonate's transfer to the intensive care unit Because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of Impaired parenting related to the neonate's transfer to the neonatal intensive care unit. (Another pertinent nursing diagnosis may be Compromised family coping related to lack of opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.

During the active phase of the first stage of labor, a client undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority? 1. Deficient knowledge (testing procedure) related to amniotomy 2. Ineffective fetal cerebral tissue perfusion related to cord compression 3. Acute pain related to increasing strength of contractions 4. Risk for infection related to rupture of membranes

2. Ineffective fetal cerebral tissue perfusion related to cord compression Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed by the presenting fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen supply. Because lack of oxygen to the fetus may cause fetal death, the nursing diagnosis of Ineffective fetal cerebral tissue perfusion takes priority over diagnoses of Deficient knowledge, Acute pain, and Risk for infection.

The nurse notices that a large number of clients who receive oxytocin (Pitocin) to induce labor, vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene? 1. Notify the physicians and explain that they need to teach their clients before inducing labor. 2. Initiate a unit policy involving staff nurses, certified nurse midwives, and physicians in teaching clients before labor induction. 3. Report the physicians for providing inferior care. 4. Initiate a protocol order that allows the nurse to administer promethazine (Phenergan) before administering oxytocin.

2. Initiate a unit policy involving staff nurses, certified nurse midwives, and physicians in teaching clients before labor induction. The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Option 1 blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the problem — the lack of client education.

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? 1. Active phase 2. Latent phase 3. Expulsive phase 4. Transitional phase

2. Latent phase The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.

A client is in the 8th month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position? 1. Right lateral 2. Left lateral 3. Supine 4. Fowler's

2. Left lateral The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

On a client's first postpartum day, the nurse assesses the client's vaginal discharge as dark red and containing shreds of decidua and mucus. What term should the nurse use in her nurse's notes to describe the discharge? 1. Lochia alba 2. Lochia rubra 3. Lochia serosa 4. Lochia

2. Lochia rubra For the first 3 days after birth, a lochia discharge consists almost entirely of blood with only small particles of decidua and mucus. Because of its red color, it's called lochia rubra. Lochia alba contains primarily leukocytes and decidual cells, and appears creamy white, brown, or almost colorless. Lochia serosa contains serous fluid, decidual tissue, leukocytes, and erythrocytes; it appears pink-brown and is serous and odorless. Lochia is the general term for postpartal vaginal discharge. It doesn't describe the discharge the nurse notes.

During the first trimester, the nurse evaluates a pregnant client for factors that suggest she might abuse a child. Which parental characteristic is a risk factor for committing child abuse? 1. Low educational level 2. Low self-esteem 3. Multiparity 4. Poor diet

2. Low self-esteem Typically, the abusive parent has low self-esteem along with many unmet needs. Lack of nurturing experience and inadequate knowledge of childhood growth and development may also contribute to the potential for child abuse. A low educational level, multiparity, and poor diet aren't direct risk factors for committing child abuse.

A nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse includes which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

2. Maintaining standard precautions at all times while caring for the newborn An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn.

During the fourth stage of labor, the nurse notes that the client's fundus is boggy and located above the umbilicus. How should the nurse intervene? 1. Let the condition resolve spontaneously. 2. Massage the client's fundus. 3. Instruct the client to bear down. 4. Notify the physician or nurse-midwife.

2. Massage the client's fundus. A boggy (soft and poorly contracted) fundus signals uterine atony. To correct this condition, the nurse should massage the fundus until it becomes firm and clots are expressed. Allowing a boggy fundus to persist would place the client at high risk for postpartum hemorrhage. Bearing down doesn't affect uterine involution. The nurse should notify the physician or nurse-midwife only if the client's fundus doesn't respond to massage.

After admission to the labor and delivery area, a client undergoes routine tests, including a complete blood count, urinalysis, Venereal Disease Research Laboratory test, and gonorrhea culture. The gonorrhea culture is positive, although the client lacks signs and symptoms of this disease. What is the significance of this finding? 1. Maternal gonorrhea may cause a neural tube defect in the fetus. 2. Maternal gonorrhea may cause an eye infection in the neonate. 3. Maternal gonorrhea may cause acute liver changes in the fetus. 4. Maternal gonorrhea may cause anemia in the neonate.

2. Maternal gonorrhea may cause an eye infection in the neonate. Gonorrhea in the cervix may cause neonatal eye infection during delivery as well as a serious puerperal infection in the client. Maternal gonorrhea isn't associated with neural tube defects, acute fetal liver changes, or neonatal anemia.

During labor, a primigravid client receives epidural anesthesia, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia? 1. Increased variability 2. Maternal hypotension 3. Fetal tachycardia 4. Maternal oliguria

2. Maternal hypotension As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, decreased variability, and fetal bradycardia. Although the client may experience some postpartum urine retention, maternal oliguria isn't associated with epidural anesthesia.

Which of the following assessment findings would the nurse interpret as abnormal for a term male neonate who's 1 hour old? 1. Enlargement of the mammary glands 2. Slight yellowish hue to the skin 3. Blue hands and feet 4. Black and blue spots on the infant's buttocks

2. Slight yellowish hue to the skin A slight yellowish hue to the skin would be abnormal because it's too early for the neonate to be showing signs of jaundice. The finding should be reported immediately to the neonate's health care provider. All of the remaining responses are normal findings for a 1-hour-old male neonate.

Which client is most appropriate for the registered nurse to assign to the licensed practical nurse (LPN)? 1. Multiparous woman who just received ergonovine maleate (Ergot) 2. Multiparous woman with Klebsiella pneumoniae cystitis 3. Multiparous woman with Enterobacter cystitis and sickle cell crisis 4. Multiparous woman with polymicrobial necrotizing fasciitis.

2. Multiparous woman with Klebsiella pneumoniae cystitis The klebsiella pneumoniae organism is a common cause of cystitis. The care of this client is appropriate for the registered nurse (RN) to delegate to the LPN. Ergonovine is prescribed for postpartum hemorrhage. Because the client recently received the medication, she might be unstable, which would require the RN's assessment skills. Enterobacter commonly causes cystitis; however, the client's condition is complicated by sickle cell crisis, which requires the care of an RN. Necrotizing fasciitis is characterized by erythema, discharge, severe pain, severe tissue necrosis, and partial liquefaction of fascia; the severity of the disease requires that an RN administer care.

At 40 weeks' gestation, a client is admitted to the labor and delivery area. She and her husband are worried about the fetus's health because she had problems during her previous childbirth. The nurse reassures them that the fetus will be monitored closely with an electronic fetal monitor (EFM). On the fetal monitor strip, what is the single most reliable indicator of fetal well-being? 1. Normal long-term variability 2. Normal short-term variability 3. Normal baseline fetal heart rate (FHR) 4. Normal contraction sequence

2. Normal short-term variability Normal short-term variability — 2 to 3 beats per amplitude — is the single most reliable indicator of fetal well-being on an EFM strip. It represents actual beat-to-beat fluctuations in the FHR. Normal long-term variability, although a helpful indicator, takes into account larger periodic and rhythmic deviations above and below the baseline FHR. Baseline FHR serves only as a reference for all subsequent FHR readings taken during labor. Contraction sequence provides no information about fetal well-being, although it does give some indication of maternal well-being and progress.

At the beginning of the shift on the postpartum unit, the charge nurse notices that the licensed practical nurse (LPN) she's working with is acting inappropriately and smells of alcohol. When the charge nurse confronts the LPN, the LPN apologizes and promises that she'll never report to work in this condition again. Which step should the charge nurse take next? 1. Rearrange the nursing assignment so that the LPN performs paperwork for the rest of the shift. 2. Notify the shift supervisor and rearrange the client care assignment. 3. Assign the LPN to the nursery where she can sit and rock babies. 4. Tell her that she's acting irresponsibly and that it better not happen again.

2. Notify the shift supervisor and rearrange the client care assignment. The charge nurse should notify the shift supervisor and rearrange the client care assignment. An impaired worker can't remain in the clinical area doing paperwork or taking care of neonates in the nursery. She should be accompanied from the area by the shift supervisor. Telling the LPN that she's acting irresponsibly and warning her that the incident better not reoccur doesn't help the impaired worker. The impaired worker should receive counseling to overcome her problem.

A client comes to the office for her first prenatal visit. She reports that January 3 was the first day of her last menstrual period. According to Nägele's rule, what date should the nurse record as the estimated date of delivery (EDD)? 1. November 10 2. October 10 3. September 10 4. December 10

2. October 10 The nurse can calculate EDD using Nägele's rule (add 7 days to the first day of the last menstrual period, then subtract 3 months, and finally add 1 year). In this example, January 3 + 7 days = January 10. 3 months prior to that date is October 10 of the previous year. Adding 1 year, her EDD is October 10 of the current year.

The nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? 1. One fingerbreadth above the umbilicus 2. One fingerbreadth below the umbilicus 3. At the level of the umbilicus 4. Below the symphysis pubis

2. One fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the 1st postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis.

A nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is an initial nursing action? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. 3. Find the closest telephone and page the physician stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.

2. Place the client in Trendelenburg's position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. The examiner may place a gloved hand into the vagina, however, and hold the presenting part off the umbilical cord. Oxygen , 8 to 10 L/ min, by face mask is administered to the client to increase fetal oxygenation.

The nurse is reviewing a client's prenatal history. Which finding indicates a genetic risk factor? 1. The client is 25 years old. 2. The client has a child with cystic fibrosis. 3. The client was exposed to rubella at 36 weeks' gestation. 4. The client has a history of preterm labor at 32 weeks' gestation.

2. The client has a child with cystic fibrosis. Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age isn't a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history of preterm labor may place the client at risk for preterm labor, it doesn't correlate with genetic defects.

A rubella titer result of a 1-day postpartum client is less than 1: 8, and a rubella virus vaccine is prescribed to be administered before discharge . The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. A hypersensitivity reaction can occur if the client has an allergy to eggs. 5. Exposure to immunosuppressed individuals needs to be avoided. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. A hypersensitivity reaction can occur if the client has an allergy to eggs. 5. Exposure to immunosuppressed individuals needs to be avoided. Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.

A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action? 1. Administer amnioinfusion. 2. Prepare for cesarean delivery. 3. Reposition the client. 4. Start I.V. oxytocin infusion as prescribed.

2. Prepare for cesarean delivery. Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean delivery. Amnioinfusion is indicated when the only abnormal fetal finding is meconium-stained amniotic fluid. Client repositioning may improve uteroplacental perfusion but only serve as a temporary measure because the risk of fetal asphyxia is imminent. Oxytocin administration increases contractions, exacerbating fetal stress.

A client who's being admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? 1. Placing the client in bed to begin fetal monitoring 2. Preparing for immediate delivery 3. Checking for ruptured membranes 4. Providing comfort measures

2. Preparing for immediate delivery This question requires an understanding of station as part of the intrapartal assessment process. Based on the client's assessment findings, this client is ready for delivery, which is the nurse's top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery.

The nurse suggests breast pumping to relieve a client's breast engorgement. Which instruction should the nurse provide? 1. Pump each breast for 5 to 10 minutes every 3 to 4 hours around the clock. 2. Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if awake. 3. Pump each breast for no more than 10 minutes every 2 hours around the clock. 4. Pump each breast for 10 minutes every 2 hours; skip one pumping at night.

2. Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if awake. To relieve engorgement, the client should pump each breast for at least 10 minutes every 3 to 4 hours during the day and should pump at night only if awake. She should try to pump for at least 100 minutes every 24 hours. Pumping every 3 to 4 hours allows the milk supply to build up. Pumping for 10 minutes or more allows the mother to obtain the rich, more filling hindmilk for the infant. Waking up just to pump interferes with the mother's rest.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on assessment? 1. Proteinuria of 3 + 2. Respirations of 10 breaths/ min 3. Presence of deep tendon reflexes 4. Serum magnesium level of 6 mEq/ L

2. Respirations of 10 breaths/ min Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/ L. Proteinuria of 3 + is an expected finding in a client with preeclampsia.

A female neonate born by elective cesarean section to a 25-year-old mother weighs 3,265 g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which sign? 1. Temperature instability due to type of birth 2. Respiratory distress due to lack of contractions 3. Signs of acrocyanosis 4. Unstable blood sugars

2. Respiratory distress due to lack of contractions The squeezing action of the contractions during labor enhances fetal lung maturity. Neonates who aren't subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing to do with temperature or glucose stability, and acrocyanosis is a normal finding.

A client in labor has been pushing effectively for 1 hour. A nurse determines that the client's primary physiological need at this time is to: 1. Ambulate 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2. Rest between contractions The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided. Food and fluids likely are to be withheld at this time.

A nurse is planning care for a newborn of a diabetic mother. A priority nursing diagnosis for this infant is: 1. Hyperthermia related to excess fat and glycogen 2. Risk for injury related to low blood glucose levels 3. Risk for delayed development related to excessive size 4. Risk for aspiration related to impaired suck and swallow reflexes

2. Risk for injury related to low blood glucose levels The newborn of a diabetic mother is at risk for hypoglycemia, so Risk for injury related to low blood glucose levels would be a priority nursing diagnosis. The newborn would also be at risk for hyperbilirubinemia , respiratory distress, hypocalcemia, and congenital anomalies. Hyperthermia, risk for delayed development, and risk for aspiration are not expected problems.

A newly hired nurse on unit orientation prepares to administer vitamin K (AquaMEPHYTON) to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best? 1. Praise the nurse for accurately preparing to administer the injection. 2. Stop the nurse and have her reevaluate her injection techniques 3. Distract the neonate by talking to her in a calm voice. 4. Stop the nurse and instruct her to administer the vitamin K using the Z-track method.

2. Stop the nurse and have her reevaluate her injection techniques Vitamin K should be administered by intramuscular (I.M.) injection. Therefore, the nurse preceptor should stop the nurse and have her reevaluate her injection techniques. The nurse preceptor can praise the nurse after the injection is administered correctly. The nurse preceptor can distract the neonate by talking calmly to her, but she should first stop the nurse from administering the medication by the wrong route. The injection should be administered by the I.M. route, not by the Z-track method.

After a precipitous delivery, a nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse should do which of the following to help the woman process what has happened? 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction on the birth record.

2. Support the mother in her reaction to the newborn infant. Precipitous labor is labor that lasts less than 3 hours. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.

During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis? 1. Hold the neonate loosely and gently. 2. Support the neonate's head and back with the forearm. 3. Use one hand to support the neonate's head. 4. Strap the neonate into the bath basin.

2. Support the neonate's head and back with the forearm. To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with the forearm. A loose hold may increase the risk of dropping the neonate. The nurse must support the neonate's back and head. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.

The nurse is assessing the psychosocial status of a postpartum client. Which finding is most likely to promote parent-neonate attachment? 1. Parental desire to bond with the neonate 2. Sustained parent-neonate contact immediately after delivery 3. Parental understanding of the importance of parent-neonate bonding 4. Previous positive childbirth experience

2. Sustained parent-neonate contact immediately after delivery Sustained parent-neonate contact immediately after delivery is most likely to promote parent-neonate attachment. The first period of neonatal reactivity, which occurs during the 1st hour after delivery, is the ideal time for behavior that promotes attachment, such as touching, holding, talking, examining, and breast-feeding. Although parental desire to bond and understanding of the importance of bonding can contribute to parent-neonate attachment, early contact is a prerequisite. A previous positive childbirth experience may enhance parent-neonate attachment but is less crucial than sustained contact immediately after delivery.

The nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do? 1. Continue assisting with the circumcision and ask the mother to sign the consent form after the procedure. 2. Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. 3. Inform the physician and ask him to quickly complete the procedure. 4. Notify the medical director of the physician's negligence.

2. Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Parents have the legal right to decide whether their son is circumcised. The nurse and physician should always check the medical record for a signed informed consent form before beginning any procedure. It's unacceptable for the nurse to ask for consent after the procedure. Quickly completing the circumcision is also unacceptable because an informed consent form wasn't signed. Both the nurse and physician were negligent for not checking for a signed informed consent form.

A client who is 29 weeks pregnant comes to the labor and delivery unit. She states that she's having contractions every 8 minutes. The client is also 3 cm dilated. Which medications can the nurse expect to administer? 1. Folic acid (Folvite) 2. Terbutaline (Brethine) 3. Betamethasone 4. Rho (D) immune globulin (Rhogam) 5. I.V. fluids 6. Meperidine (Demerol)

2. Terbutaline (Brethine) 3. Betamethasone 5. I.V. fluids The client is at risk for preterm delivery. The nurse can expect that terbutaline, a beta-2 agonist that relaxes smooth muscle, will be administered to halt contractions. The nurse can also expect that betamethasone, a corticosteroid, will be administered to decrease the risk of respiratory distress in the infant if preterm delivery occurs. I.V. fluids will be used to expand the intravascular volume and decrease contractions, if dehydration is the cause. Folic acid is a mineral recommended throughout pregnancy (especially in the first trimester) to decrease the risk of neural tube defects. It isn't used to address preterm delivery. Rho (D) immune globulin is administered to Rh-negative clients who have been or are suspected of having been exposed to Rh-positive fetal blood. Meperidine is an opioid used during labor and delivery to manage pain.

A nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding would indicate that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida. 2. The client has a history of cardiac disease. 3. The client's hemoglobin level is 13.5 g/ dL. 4. The client is a 20-year-old primigravida of average weight and height.

2. The client has a history of cardiac disease. Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems , social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.

After an amniotomy, which client goal should take the highest priority? 1. The client will express increased knowledge about amniotomy. 2. The client will maintain adequate fetal tissue perfusion. 3. The client will display no signs of infection. 4. The client will report relief of pain.

2. The client will maintain adequate fetal tissue perfusion. Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus's life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief.

When assessing the fetal heart rate tracing, the nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if which of the following occurs? 1. The fetal heart rate remains at greater than 160 beats/minute for 5 minutes. 2. The fetal heart rate remains at greater than 160 beats/minute for 10 minutes. 3. The fetal heart rate remains at greater than 160 beats/minute for more than 20 minutes. 4. The fetal heart rate is at least 170 beats/minute at any time.

2. The fetal heart rate remains at greater than 160 beats/minute for 10 minutes. The normal parameter for the fetal heart rate is 120 to 160 beats/minute. Tachycardia is defined as a fetal heart rate greater than 160 beats/minute for more than 10 minutes. This definition takes into account the difference between tachycardia and acceleration.

Which statement describes the rationale for administering vitamin K to every neonate? 1. Neonates don't receive the clotting factor in utero. 2. The neonate lacks intestinal flora to make the vitamin. 3. It boosts the minimal level of vitamin K found in the neonate. 4. The drug prevents the development of phenylketonuria (PKU).

2. The neonate lacks intestinal flora to make the vitamin. Neonates are at risk for bleeding disorders during the 1st week of life because their GI tracts are sterile at birth and lack the intestinal flora needed to produce vitamin K, which is necessary for blood coagulation. Vitamin K stimulates the liver to produce clotting factors. Vitamin K doesn't prevent PKU, which is an inherited metabolic disease.

The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate? 1. They're regular. 2. They're usually felt in the abdomen. 3. They start in the back and radiate to the abdomen. 4. They become more intense during walking.

2. They're usually felt in the abdomen. Prelabor contractions are usually felt in the abdomen. In contrast, true labor contractions are regular, start in the back and radiate to the abdomen, and become more intense during walking.

The physician placed a direct fetal scalp electrode on the fetus. What should the nurse include when documenting direct fetal scalp electrode placement? 1. Time of fetal scalp electrode placement, name of the physician who placed the electrode, and frequency of uterine contractions. 2. Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR). 3. The name of the physician who applied the electrode, Doppler transducer placement, and FHR. 4. The maternal and fetal body movements identified by the direct fetal scalp electrode, time of fetal scalp electrode placement, and FHR.

2. Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR). Direct fetal scalp electrode placement is the most accurate way to assess FHR. Documentation should include the time the electrode was placed, the name of the physician or nurse practitioner who performed the procedure, and the FHR. Direct fetal scalp electrodes don't monitor maternal uterine contractions. A Doppler transducer (an external, not internal device) is applied to the mother's abdomen to measure FHR, using high-frequency ultrasound. Unlike the fetal scalp electrode, it doesn't directly measure FHR. The fetal scalp electrode doesn't measure maternal or fetal movements.

The physician decides to artificially rupture the membranes. Following this procedure, the nurse checks the fetal heart tones for which reason? 1. To determine fetal well-being 2. To assess for fetal bradycardia 3. To assess fetal position 4. To prepare for an imminent delivery

2. To assess for fetal bradycardia After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.

A nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

2. Uterine tenderness Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability.

A nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. The nurse tells the client to: 1. Avoid wearing a bra. 2. Wash the breasts with warm water and keep them dry. 3. Wear tight-fitting blouses or dresses to provide support. 4. Wash the nipples and areolar area daily with soap, and massage the breasts with lotion.

2. Wash the breasts with warm water and keep them dry. The pregnant client should be instructed to wash the breasts with warm water and keep them dry . The client should be instructed to avoid using soap on the nipples and areolar area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-fitting blouses or dresses cause discomfort. The client is instructed to wear soft-textured clothing to decrease nipple tenderness and to use breast pads inside the bra to prevent leakage through the clothing if colostrum is a problem.

The nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure? 1. Washing the hands 2. Washing the hands and wearing latex gloves 3. Washing the hands and wearing latex gloves and a barrier gown 4. Washing the hands and wearing latex gloves, a barrier gown, and protective eyewear

2. Washing the hands and wearing latex gloves During a postpartum assessment, the nurse is likely to come into contact with the client's blood or body fluids, especially when examining the perineal region. Therefore, the nurse must wear latex gloves; hand washing alone would neither provide adequate protection nor comply with universal precautions. The nurse should wear a barrier gown and protective eyewear in addition to latex gloves only when anticipating splashing of blood or body fluids such as during childbirth. Splashing isn't likely to occur during a postpartum assessment.

A primigravid client delivers a full-term girl. When teaching the client and her husband how to change their neonate's diaper, the nurse should instruct them to: 1. fold a cloth diaper so that a double thickness covers the front. 2. clean and dry the neonate's perineal area from front to back. 3. place a disposable diaper over a cloth diaper to provide extra protection. 4. position the neonate so that urine will fall to the back of the diaper.

2. clean and dry the neonate's perineal area from front to back. When changing a female neonate's diaper, the caregiver should clean the perineal area from front to back to prevent infection and then dry the area thoroughly to minimize skin breakdown. For a male, the caregiver should clean and dry under and around the scrotum. Because of anatomic factors, a female's diaper should have the double thickness toward the back. The diaper, not the neonate, should be positioned properly. Placing a disposable diaper over a cloth diaper isn't necessary. The direction of urine flow can't be ensured.

After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. This assessment indicates the client is: 1. exhibiting normal signs of an ovulatory stimulant. 2. demonstrating signs of hyperstimulation syndrome. 3. is probably pregnant. 4. is having a reaction to the menotropins.

2. demonstrating signs of hyperstimulation syndrome. Characterized by abdominal swelling from ascites, weight gain, and peripheral edema, hyperstimulation syndrome from ovulatory stimulants is an unusual occurrence. This client must be admitted to the hospital for management of the disorder. Nursing care includes emotional support to reduce anxiety and management of symptoms. These signs aren't signs of pregnancy and aren't normal reactions to ovulatory stimulants.

The nurse is assessing a client on the 2nd postpartum day. Under normal circumstances, the tone and location of the client's fundus is: 1. soft and one fingerbreadth below the umbilicus. 2. firm and two fingerbreadths below the umbilicus. 3. firm and to the right or left of midline. 4. soft and at the level of the umbilicus.

2. firm and two fingerbreadths below the umbilicus. By the 2nd postpartum day, the fundus should be firm and two fingerbreadths below the umbilicus. The fundus should be at the level of the umbilicus on the day of delivery and falls below the umbilicus by approximately one fingerbreadth (1 cm) per day, until it has contracted into the pelvis by the 9th or 10th day. The fundus should be firm, not soft. A soft or boggy fundus indicates that the uterus isn't contracting properly. The fundus should be palpated in the midline of the abdomen; if the woman has a full bladder, however, the fundus may be deviated to the right or left.

A client makes a routine visit to the prenatal clinic. Although she's 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. The physician diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: 1. an empty gestational sac. 2. grapelike clusters. 3. a severely malformed fetus. 4. an extrauterine pregnancy.

2. grapelike clusters. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy.

A client and her boyfriend of five months are celebrating the birth of a healthy baby boy when the client's estranged husband arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged husband has the right to: 1. see the infant through the nursery glass window. 2. hold the infant after the mother gives permission. 3. ask security to remove the boyfriend from his estranged wife's hospital room. 4. decide to circumcise his son.

2. hold the infant after the mother gives permission. The baby's mother has legal control over the neonate she just delivered. Therefore, the mother must grant permission for her estranged husband to hold him. The neonate commonly stays in the mother's room, not in the nursery. Therefore, looking through the nursery window isn't an option. The estranged husband can't ask to have the boyfriend removed because the client wants him to remain. The mother must sign the consent for circumcision.

A client who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse expects to find: 1. lethargy 2 days after birth. 2. irritability and poor sucking. 3. a flattened nose, small eyes, and thin lips. 4. congenital defects such as limb anomalies.

2. irritability and poor sucking. Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies.

Moments after birth, a neonate of 32 weeks' gestation develops asphyxia. As the neonatal team starts resuscitation, the nurse must: 1. hyperextend the neonate's neck. 2. keep the neonate's head in the "sniff" position. 3. maintain the neonate's head in a neutral position. 4. turn the neonate's head slightly to one side.

2. keep the neonate's head in the "sniff" position. To open the airway, the nurse must keep the neonate's head in the "sniff" position by extending the neck slightly. Hyperextending the neck, keeping the head in a neutral position, or turning the head to one side wouldn't open the neonate's airway.

After 2 days of breast-feeding, a postpartum client reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: 1. apply warm compresses to her nipples just before feedings. 2. lubricate her nipples with expressed milk before feedings. 3. dry her nipples with a soft towel after feedings. 4. apply soap directly to her nipples and then rinse.

2. lubricate her nipples with expressed milk before feedings. Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.

The nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this client, the nurse's highest priority is to evaluate: 1. cervical effacement and dilation. 2. maternal vital signs and fetal heart rate (FHR). 3. frequency and duration of contractions. 4. white blood cell (WBC) count.

2. maternal vital signs and fetal heart rate (FHR). After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this client because it requires a pelvic examination, which may introduce pathogens into the birth canal. Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and FHR can and therefore provides less current information.

When assessing a neonate who was born at 30 weeks' gestation, the nurse notes bounding femoral pulses, a palpable thrill over the suprasternal notch, tachycardia, tachypnea, and crackles. The nurse suspects: 1. ventricular septal defect. 2. patent ductus arteriosus. 3. tetralogy of Fallot. 4. atrial septal defect.

2. patent ductus arteriosus. Patent ductus arteriosus causes tachycardia, tachypnea, a palpable thrill over the suprasternal notch, hepatomegaly, bounding peripheral pulses, widened pulse pressure, a continuous or systolic heart murmur, increased heart pulsation, and signs of respiratory distress or heart failure (such as increasing respiratory effort, crackles or moist breath sounds, feeding intolerance, fatigue, and decreasing urine output). Ventricular and atrial septal defects rarely cause signs at birth, although a neonate with an atrial septal defect may have a systolic murmur. With tetralogy of Fallot, the neonate typically has cyanosis, dyspnea, and a continuous murmur that is audible across the back.

The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward: 1. ensuring adequate nutrition. 2. preventing infection. 3. promoting neural tube sac drainage. 4. conserving body heat.

2. preventing infection. The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, the infant with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac.

A client, 7 months pregnant, is receiving the tocolytic agent terbutaline (Bricanyl), 17.5 mcg/minute I.V., to halt uterine contractions. She also takes prednisone (Orasone), 5 mg by mouth twice per day, to control asthma. To detect an adverse interaction between these drugs, the nurse should monitor the client for: 1. increased uterine contractions. 2. pulmonary edema. 3. asthma exacerbation. 4. hypertensive crisis.

2. pulmonary edema. When administered concomitantly with prednisone or another corticosteroid, terbutaline may cause pulmonary edema. Concomitant administration of a corticosteroid and terbutaline doesn't cause increased uterine contractions, asthma exacerbation, or hypertensive crisis.

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. To resolve this problem, the nurse should suggest that she: 1. tilt the bottle so that the nipple fills with formula. 2. stroke the neonate's lips gently with the nipple. 3. use a nipple with the largest possible openings. 4. push only the tip of the nipple into the neonate's mouth.

2. stroke the neonate's lips gently with the nipple. Stroking the neonate's lips gently with the nipple usually causes the mouth to open wide enough for nipple insertion. Tilting the bottle or pushing the tip of the nipple into the neonate's mouth may cause continued difficulty. Using a nipple with larger openings wouldn't help resolve the problem and may cause too much formula to enter the mouth once the neonate starts to suck. The tip of the nipple shouldn't be pushed into the infant's mouth. To suck effectively, the infant needs to compress the entire nipple, not just the tip.

To minimize the amount of a drug received by an infant through breast-feeding, the nurse should tell the mother to: 1. take the medication immediately before breast-feeding. 2. take the medication immediately after breast-feeding. 3. feed the infant 2 hours after taking the medication. 4. feed the infant 4 hours after taking the medication.

2. take the medication immediately after breast-feeding. To minimize the amount of a drug received by an infant, the nurse should tell the mother to take the medication immediately after breast-feeding. Feeding the infant within 4 hours after taking the medication increases the risk of the drug being present in breast milk.

A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to telling the client how important taking the vitamins are, the nurse should advise her to: 1. switch brands. 2. take the vitamin on a full stomach. 3. take the vitamin with orange juice for better absorption. 4. take the vitamin first thing in the morning.

2. take the vitamin on a full stomach. Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea.

The nurse is providing care for a pregnant woman. The woman asks the nurse how she can best deal with her fatigue. The nurse should instruct her to: 1. take sleeping pills for a restful night's sleep. 2. try to get more rest by going to bed earlier. 3. take her prenatal vitamins. 4. tell her not to worry because the fatigue will go away soon.

2. try to get more rest by going to bed earlier. She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now.

A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings signify: 1. an infection. 2. umbilical cord prolapse. 3. the start of the second stage of labor. 4. the need for labor induction.

2. umbilical cord prolapse. After an amniotomy, a significant change in the FHR may indicate umbilical cord prolapse; an EFM may show large variable decelerations during cord compressions. The other options aren't associated with FHR changes. An infection causes temperature elevation. The second stage of labor starts with complete cervical dilation. Labor induction is indicated if the client's labor fails to progress.

A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for: 1. uterine inversion. 2. uterine atony. 3. uterine involution. 4. uterine discomfort.

2. uterine atony. Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.

The average expected weight gain during pregnancy for women with a normal prepregnancy weight

25 to 35 lb

A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I should stay on the diabetic diet." 2. "I should perform glucose monitoring at home." 3. "I should avoid exercise because of the negative effects on insulin production." 4. "I should be aware of any infections and report signs of infection immediately to my health care provider."

3. "I should avoid exercise because of the negative effects on insulin production." Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or health care provider's office. Signs of infection need to be reported to the health care provider.

A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician prescribes bethanechol (Duvoid), 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond? 1. "It constricts the urinary sphincter." 2. "It dilates the urethra." 3. "It stimulates the smooth muscle of the bladder." 4. "It inhibits the skeletal muscle of the bladder."

3. "It stimulates the smooth muscle of the bladder." Bethanechol stimulates the smooth muscle of the bladder, causing it to release retained urine. Bethanechol doesn't act on the urinary sphincter or dilate the urethra. The bladder contains smooth muscle, not skeletal muscle.

The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: 1. "Now isn't a good time to begin dieting because you are eating for two." 2. "Let's explore your feelings further." 3. "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." 4. "The prenatal vitamins should ensure the baby gets all the necessary nutrients."

3. "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." Depriving the developing fetus of nutrients can cause serious problems and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or baby needs; they work in congruence with a balanced diet.

A pregnant client in the first trimester calls a nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2. "Report to the emergency department at the maternity center immediately." 3. "The vaginal discharge may be bothersome, but is a normal occurrence." 4. "Use tampons if the discharge is bothersome , but to be sure to change the tampons every 2 hours."

3. "The vaginal discharge may be bothersome, but is a normal occurrence." Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy . Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently.

A 30-year-old primiparous client at 34 weeks' gestation comes to the prenatal facility concerned about the reddish streaks she has increasingly developed on her breasts and abdomen. She asks what these skin changes are and whether they're permanent. What should the nurse tell her? 1. "These streaks are called linea nigra; they'll fade after childbirth." 2. "These streaks are called hemangiomas; they're permanent changes of pregnancy." 3. "These streaks are called striae gravidarum, or stretch marks; they'll grow lighter after delivery." 4. "These streaks are called nevi; they'll fade after the postpartum period."

3. "These streaks are called striae gravidarum, or stretch marks; they'll grow lighter after delivery." The client's weight gain and enlarging uterus, combined with the action of adrenocorticosteroids, lead to stretching of the underlying connective tissue of the skin, creating striae gravidarum in the second and third trimesters. Better known as stretch marks, these streaks develop most often in skin covering the breasts, abdomen, buttocks, and thighs. After delivery, they typically grow lighter. Linea nigra is a dark line that extends from the umbilicus or above to the mons pubis. In the primigravid client, this line develops at approximately the 3rd month of pregnancy. In the multigravid client, linea nigra typically appears before the 3rd month. Tiny bright hemangiomas may occur during pregnancy as a result of estrogen release. They're called vascular spiders because of the branching pattern that extends from each spot. Nevi are circumscribed, benign proliferations of pigment-producing cells in the skin.

A client who's 4 months pregnant asks the nurse how much and what type of exercise she should get during pregnancy. How should the nurse counsel her? 1. "Try high-intensity aerobics, but limit sessions to 15 minutes daily." 2. "Perform gentle back-lying exercises for 30 minutes daily." 3. "Walk briskly for 10 to 15 minutes daily, and gradually increase this time." 4. "Exercise to raise the heart rate above 140 beats/minute for 20 minutes daily."

3. "Walk briskly for 10 to 15 minutes daily, and gradually increase this time." Taking brisk walks is one of the easiest ways to exercise during pregnancy. The client should begin by walking slowly for 10 to 15 minutes per day and increase gradually to a comfortable speed and a duration of 30 to 45 minutes per day. The pregnant client should avoid high-intensity aerobics because these greatly increase oxygen consumption; pregnancy itself not only increases oxygen consumption but reduces oxygen reserve. Starting from the 4th month of pregnancy, the client should avoid back-lying exercises because in this position the enlarged uterus may reduce blood flow through the vena cava. The client should avoid exercises that raise the heart rate over 140 beats/minute because the cardiovascular system already is stressed by increased blood volume during pregnancy.

A client who's 37 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client's preparation for parenting, the nurse might ask which question? 1. "Are you planning to have epidural anesthesia?" 2. "Have you begun prenatal classes?" 3. "What changes have you made at home to get ready for the baby?" 4. "Can you tell me about the meals you typically eat each day?"

3. "What changes have you made at home to get ready for the baby?" During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment. The type of anesthesia planned doesn't reflect the client's preparation for parenting. The client should have begun prenatal classes earlier in the pregnancy. The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes.

Accompanied by her husband, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? 1. "Do you have any chronic illnesses?" 2. "Do you have any allergies?" 3. "What is your expected due date?" 4. "Who will be with you during labor?"

3. "What is your expected due date?" When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons.

The nurse is assessing the fetal heart rate (FHR) of a client, who is at term, admitted to the labor and delivery area. Which of the following should the nurse identify as the normal range of the baseline FHR? 1. 60 to 80 beats/minute 2. 80 to 120 beats/minute 3. 120 to 160 beats/minute 4. 160 to 200 beats/minute

3. 120 to 160 beats/minute In a full-term fetus, the baseline FHR normally ranges from 120 to 160 beats/minute. FHR below 120 beats/minute reflects bradycardia; above 160 beats/minute, tachycardia.

At what gestational age would a primigravida expect to feel quickening? 1. 12 weeks 2. 16 to 18 weeks 3. 20 to 22 weeks 4. By the end of the 26th week

3. 20 to 22 weeks It's important for the nurse to distinguish between a client who's having her first baby and one who has already had a baby. For the client who's pregnant for the first time, quickening occurs around 20 to 22 weeks. Women who have had children will feel quickening earlier, usually around 18 to 20 weeks, because they recognize the sensations.

A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: 1. return to preovulatory basal body temperature. 2. basal body temperature increase of 0.1° F to 0.2° F (0.06° C to 0.11° C) on the 2nd or 3rd day of the cycle. 3. 3 full days of elevated basal body temperature and clear, thin cervical mucus. 4. breast tenderness and mittelschmerz.

3. 3 full days of elevated basal body temperature and clear, thin cervical mucus. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7° F to 0.8° F (.39° C to .44° C) and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle isn't significant. Breast tenderness and mittelschmerz aren't reliable indicators of ovulation.

A client plans to bottle-feed her full-term neonate. What is the normal feeding pattern for a full-term neonate during the first 24 hours after delivery? 1. 120 ml of formula every 2 to 3 hours 2. 80 to 100 ml of formula every 2 hours 3. 40 to 60 ml of formula every 2 to 4 hours 4. 20 to 40 ml of formula every 3 hours

3. 40 to 60 ml of formula every 2 to 4 hours The neonate's gastric capacity ranges from 40 to 60 ml during the first 24 hours after delivery. Nutrient needs must be met through frequent, small-volume feedings. Gastric emptying time — typically 2 to 4 hours — varies with feeding volume and the neonate's age. The neonate can't tolerate 80 to 100 ml every 2 hours or 120 ml every 2 to 3 hours. Giving 20 to 40 ml every 3 hours wouldn't meet the neonate's nutritional needs.

After a client delivers a boy, the nurse assesses the neonate to obtain the Apgar score. Findings include a heart rate of 120 beats/minute, a vigorous cry, some muscle tone in the arms and legs but a less-than-brisk response, movement and crying in response to light flicking of the sole, and pink skin, except for bluish hands and feet. The nurse should assign which Apgar score? 1. 10 2. 9 3. 8 4. 7

3. 8 The Apgar score is based on heart rate, respiration, muscle tone, reflex irritability, and color. A heart rate above 100 beats/minute rates a 2; below 100 beats/minute, 1; no heartbeat, 0. Regular respirations or vigorous crying rates a 2; irregular, shallow, or gasping respirations, 1; absent respiratory effort, 0. A brisk muscle response rates a 2; a slow response, 1; flaccid muscles, 0. Vigorous crying when the sole is flicked rates a 2; some motion and weak crying, 1; no response, 0. Completely pink skin rates a 2; acrocyanosis (bluish hands and feet), 1; completely pale or blue skin, 0. In this question, the neonate has an Apgar score of 8 based on a heart rate above 100 beats/minutes (2), vigorous crying (2), slow muscle response (1), crying when the sole is flicked (2), and acrocyanosis (1).

A nurse in a maternity unit is reviewing the records of the clients on the unit. Which client would the nurse identify as being at the greatest risk for developing disseminated intravascular coagulation? 1. A primigravida with mild preeclampsia 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida II who has just been diagnosed with dead fetus syndrome 4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood

3. A gravida II who has just been diagnosed with dead fetus syndrome In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the clotting cascade is activated , resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large infant is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

Which of the following describes a preterm neonate? 1. A neonate weighing less than 2,500 g (5 lb, 8 oz) 2. A low-birth-weight neonate 3. A neonate born at less than 37 weeks' gestation regardless of weight 4. A neonate diagnosed with intrauterine growth retardation

3. A neonate born at less than 37 weeks' gestation regardless of weight A preterm neonate is a neonate born at less than 37 weeks' gestation regardless of what the neonate weighs. Neonates weighing less than 2,500 g are described as low-birth-weight neonates. A neonate who's small for gestational age weighs below the 10th percentile (or two standard deviations below the mean) as a result of intrauterine growth retardation.

When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following provide the most accurate picture of retention with overflow? 1. Frequent trips to the bathroom with an average output of 200 to 300 ml per void 2. Intense urge to urinate with an average output of 250 ml 3. A varying urge to urinate with an average output of 100 ml 4. Uterus displaced to the right with increased vaginal bleeding

3. A varying urge to urinate with an average output of 100 ml Retention with overflow is a commonly missed nursing assessment. Because the client may be voiding and may not have an urge to void doesn't mean that bladder function has been properly restored. A varying urge to urinate with an average urine output of 100 ml is a classic picture of a client whose bladder is distended and needs to be catheterized to restore normal function.

After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What does this finding suggest? 1. Increased bloody show 2. Normal amniotic fluid 3. Abruptio placentae 4. Meconium

3. Abruptio placentae Port-wine-colored amniotic fluid isn't normal and may indicate abruptio placentae. Increased bloody show is a normal finding and causes light pink amniotic fluid. Meconium turns amniotic fluid green.

A postpartum client tells the nurse she's having trouble moving her bowels. The nurse should recommend that she do which of the following to combat constipation? 1. Eat more cheese. 2. Maintain bed rest and avoid exercise. 3. Add high-fiber foods to her diet. 4. Limit fluid intake to 32 oz daily.

3. Add high-fiber foods to her diet. If a postpartum client has trouble moving her bowels, the nurse should recommend that she eat more high-fiber foods (such as fresh fruits and vegetables, bran, and prunes) and drink plenty of fluids (1 to 2 qt daily to replace fluids lost during labor and delivery) to promote peristalsis. Activity and exercise also aid peristalsis. Cheese isn't known to promote bowel movements.

The third stage of labor ends with which of the following? 1. The birth of the baby 2. When the client is fully dilated 3. After the delivery of the placenta 4. When the client is transferred to her postpartum bed

3. After the delivery of the placenta The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the baby. The fourth stage of labor includes the first 4 hours after birth.

When caring for a client during the second stage of labor, which action would be least appropriate? 1. Assisting the client with pushing 2. Ensuring the client's legs are positioned appropriately 3. Allowing the client clear liquids 4. Monitoring the fetal heart rate

3. Allowing the client clear liquids During this time, the client is usually offered ice chips rather than clear liquids. Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate.

A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her care plan? 1. Carefully titrating the oxytocin based on her pattern of labor 2. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes 3. Allowing the client to ambulate as tolerated 4. Helping the client use breathing exercises to manage her contractions

3. Allowing the client to ambulate as tolerated Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include.

A nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which of the following signs, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 ° F 2. A blood pressure change from 130/ 88 to 124/ 80 mm Hg 3. An increase in the pulse rate from 88 to 102 beats/ min 4. An increase in the respiratory rate from 18 to 22 breaths/ min

3. An increase in the pulse rate from 88 to 102 beats/ min During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight increase in temperature is normal. The respiratory rate is slightly increased from normal.

A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate? 1. Gently pulling at the baby's head as it's delivered 2. Holding the baby's head back until the physician arrives 3. Applying gentle pressure to the baby's head as it's delivered 4. Placing the mother in the Trendelenburg position until the physician arrives

3. Applying gentle pressure to the baby's head as it's delivered Gentle pressure applied to the baby's head as it's delivered prevents rapid expulsion, which can cause brain damage to the baby and perineal tearing in the mother. Never pull at the baby's head or hold the head back. Placing the mother in the Trendelenburg position won't halt labor and may cause respiratory difficulties.

The nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum? 1. Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate. 2. Notify the physician immediately. 3. Ask the physician for an order to obtain cultures of both of the neonate's eyes. 4. Obtain a nasal viral culture.

3. Ask the physician for an order to obtain cultures of both of the neonate's eyes. Ophthalmia neonatorum, caused by Neisseria gonorrhea, causes neonatal blindness if left untreated. The nurse should ask the physician for an order to obtain cultures of both eyes so antibiotic treatment can be initiated. Eye discharge isn't normal in a 1-day-old neonate. Neisseria gonorrhea is caused by a gram-negative bacteria, not by a virus.

The certified nurse midwife places the neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes heart rate 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next? 1. Assign an Apgar score of 7, place the neonate in modified Trendelenburg position, and begin artificial respirations. 2. Assign an Apgar score of 6, place in the neonate in modified Trendelenburg position, and initiate a code to gain assistance from the code team. 3. Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction the neonate's nose and oropharynx. 4. Assign an Apgar score of 10, place in the neonate in modified Trendelenburg position, and suction the neonate's nose.

3. Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction the neonate's nose and oropharynx. The neonate should be assigned an Apgar score of 9 because the neonate is pink, is crying vigorously, is moving all extremities, has a heart rate of 110 beats/minute, and has an irregular respiratory effort. The irregular respiratory effort and the presence of mucus in the nasal and oral cavities signify that the neonate requires suctioning. The neonate doesn't require resuscitation.

In the first stage of labor, a client with a full-term pregnancy has an electronic fetal monitoring (EFM) device in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion? 1. Persistent fetal bradycardia 2. Variable decelerations 3. Average variability 4. Late decelerations

3. Average variability A fetal heart rate with average variability (5 to 10 beats/minute) accurately predicts adequate uteroplacental-fetal perfusion. Persistent fetal bradycardia may indicate hypoxia, arrhythmia, or umbilical cord compression. Variable decelerations also suggest umbilical cord compression. Late decelerations may reflect decreased blood flow and oxygen to the intervillous spaces during contractions.

A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation? 1. By avoiding holding the eyelid open during medication instillation 2. By letting the medication drip onto the surface of the eye 3. By positioning the neonate so that the head remains still 4. By holding the neonate in the football position

3. By positioning the neonate so that the head remains still After positioning the neonate securely so that the head remains still, the nurse should hold the eyelid open and instill the medication into the conjunctival sac. Holding the neonate in the football position doesn't secure the head.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the identification bands are no longer on the neonate. Which action should the nurse take next? 1. Reprimand the parents for allowing the identification bands to come off. 2. Replace the identification bands. 3. Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to the neonate's extremities. 4. Obtain the neonate's footprints and compare them with the footprints obtained at birth.

3. Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to the neonate's extremities. The nurse should immediately compare the information on the mother's identification band with that of the neonate's, and then reattach the neonate's bands. This safety practice prevents infant abduction. Replacing the bands without first verifying identification is irresponsible. Reprimanding the parents will be detrimental to the nurse-parent relationship. The nurse isn't qualified to compare footprints.

Which measure must a graduate nurse take before working on the antepartum unit? 1. Pass the NCLEX examination 2. Observe a client going through labor and delivery 3. Complete facility and unit orientation 4. Obtain specialty certification

3. Complete facility and unit orientation A graduate nurse should complete facility and unit orientation before working in the antepartum unit. Orientation provides the nurse with information about the facilities' policies and procedures so the nurse can care for clients to the best of her ability. The graduate nurse doesn't need to pass the NCLEX examination before beginning employment. The graduate nurse doesn't need to observe a client going through labor and delivery to work in the antepartum unit. Specialty certification requires experience as a practitioner before the nurse can qualify to take the certification examination.

The staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner? 1. Assign a nursing assistant to teach a discharge class for the clients ready for discharge. 2. Show the clients an educational video. 3. Conduct a class for clients who require the same discharge teaching. 4. Organize a weekly discharge class.

3. Conduct a class for clients who require the same discharge teaching. The nurses can educate their clients more efficiently by conducting a class for those who require the same discharge teaching. This allows the other nurses to care for their other clients while the teaching is taking place. It's beyond the scope of practice for a nursing assistant to conduct an educational class for clients. Videos don't allow interaction between the teacher and client and don't provide an opportunity for discussion. Holding a weekly class doesn't meet the needs of all clients.

When a client states that her "water broke," which of the following actions would be inappropriate for the nurse to do? 1. Observing for pooling of straw-colored fluid 2. Checking vaginal discharge with nitrazine paper 3. Conducting a bedside ultrasound for an amniotic fluid index 4. Observing for flakes of vernix in the vaginal discharge

3. Conducting a bedside ultrasound for an amniotic fluid index It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes.

An adolescent in the early stages of labor is admitted to the labor and delivery unit. The nurse notes lymphadenopathy and a macular rash on the palmar surfaces of the hands and plantar surfaces of the feet. Admission laboratory testing reveals trace ketones in the urine, white blood cell count 10,000/μl, hemoglobin 14.5 g/dl, hematocrit 40%, and the nontreponemal antibody test is positive. The nurse notifies the physician of the laboratory results. Which action by the nurse takes priority? 1. Notifying the laboratory that a repeat hemoglobin and hematocrit have been ordered. 2. Recommending that the client drink plenty of fluids. 3. Consulting with the infection control nurse. 4. Asking the client if she has been exposed to varicella in the past 3 weeks.

3. Consulting with the infection control nurse. A nontreponemal test screens the client for syphilis. The positive test result, along with the lymphadenopathy and rash, indicate that the client has secondary syphilis. Based on these findings, the neonate will most likely have signs and symptoms of congenital syphilis. The hemoglobin and hematocrit results are normal for a pregnant client. The laboratory results don't show signs of dehydration, so having the client drink plenty of fluids isn't necessary. The lesions associated with varicella are vesicular, and don't resemble the rash associated with syphilis.

Six hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? 1. Low room humidity 2. Cold weight scale 3. Cool incubator walls 4. Cool room temperature

3. Cool incubator walls Common sources of radiant heat loss include cool incubator walls and windows. Low room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss.

In the maternal attachment process, which statement best describes the anticipated actions in the taking-hold phase? 1. Mother's needs being met first 2. Looking at the infant 3. Kissing, embracing, and caring for the infant 4. Talking about the baby

3. Kissing, embracing, and caring for the infant Taking-hold behaviors, the third step in parent-infant attachment, are best described by activities that involve tactile contact. These behaviors indicate that the parents have made significant strides toward taking care of their infant. Meeting the mother's needs first, looking at the infant, and talking about the baby are typically associated with the taking-in period.

During a childbirth education class, a nurse-educator discusses pain control techniques used during labor and delivery. Which technique most effectively helps a client cope with the pain of uterine contractions? 1. Controlled breathing 2. Distraction 3. Cutaneous stimulation 4. Hypnosis

3. Cutaneous stimulation Used by the client or her coach, cutaneous stimulation, such as effleurage, creates organized, controlled sensory input that reduces local irritability. In effleurage, the client concentrates on the sensation of light fingertip stroking of the abdomen or back, rather than the pain of the contraction, to help counteract the perception of pain. Controlled breathing is primarily used to enhance relaxation; although relaxation can reduce pain, it's typically less effective than cutaneous stimulation. Distraction isn't helpful because it diverts the client from the task of labor. Hypnosis is a trancelike state used to reduce attention to external stimuli.

What is the primary nursing diagnosis for a client with a ruptured ectopic pregnancy? 1. Anxiety 2. Acute pain 3. Deficient fluid volume 4. Anticipatory grieving

3. Deficient fluid volume Ruptured ectopic pregnancy is associated with hemorrhage and requires immediate surgical intervention; therefore, Deficient fluid volume is the primary diagnosis. The other options are correct but aren't the primary nursing diagnosis. This client is probably experiencing anxiety because this is a surgical emergency. Pain is also present and should be addressed as warranted. The client with ruptured ectopic pregnancy may experience anticipatory grieving at the loss of her fetus.

The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? 1. Risk for aspiration related to prematurity 2. Deficient knowledge related to ventilatory support 3. Deficient knowledge related to apneic episodes 4. Deficient knowledge related to prematurity

3. Deficient knowledge related to apneic episodes For the parents of a neonate who needs a home apnea monitor, the nursing diagnosis of Deficient knowledge related to apneic episodes is most appropriate. Although the premature neonate may be at risk for aspiration, the question asks about the most appropriate nursing diagnosis for the parents, not the neonate. No ventilatory support is being used, so a diagnosis of Deficient knowledge related to ventilatory support isn't warranted. A diagnosis of Deficient knowledge related to prematurity would be appropriate just after delivery but would probably be resolved by the time the neonate is ready for discharge.

A nurse in a delivery room is assisting with the delivery of a newborn. After delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3. Drying the infant with a warm blanket Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction . Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).

A postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3. Enlarged, hardened veins Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

A client who admits she uses heroin delivers a neonate at 32 weeks' gestation. Which neonatal assessment is most important for the nurse to perform? 1. Auscultation of breath sounds for signs of pulmonary problems 2. Careful observation of respiratory effort because of the neonate's prematurity 3. Evaluation for signs of drug withdrawal 4. Observation for jaundice

3. Evaluation for signs of drug withdrawal After delivery, the neonate of a substance abuser may exhibit signs of drug withdrawal, such as irritability, poor feeding, and continual crying. Auscultating breath sounds, observing respiratory effort, and observing for jaundice are appropriate assessments for any neonate, not just the neonate of a substance abuser.

A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by the nurse is best? 1. The fetal scalp electrode is a small device that looks like a corkscrew. It's applied quickly after the baby's scalp is carefully palpated. 2. Inform the client that she'll have to remain on bedrest after the fetal scalp electrode is applied. 3. Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. 4. Inform the client that the fetal scalp electrode helps monitor fetal heart rate and assists with shortening the first stage of labor.

3. Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. The nurse should explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Therefore, its use is contraindicated in clients that test HIV positive. Options 1 and 2 provide correct information about fetal scalp electrode application; however, they don't address the client's clinical situation, which prevents fetal scalp electrode application. The fetal scalp electrode helps monitor fetal heart rate, but it doesn't shorten labor.

Which findings would be considered positive signs of pregnancy? 1. Fatigue and skin changes 2. Quickening and breast enlargement 3. Fetal heartbeat and fetal movement on palpation 4. Abdominal enlargement and Braxton Hicks contractions

3. Fetal heartbeat and fetal movement on palpation Fetal heartbeat and fetal movement on palpation are considered positive signs of pregnancy because they can't be caused by any other condition. Fatigue can be caused by chronic illness or anemia. Skin changes can result from cardiopulmonary disorders, estrogen-progesterone oral contraceptives, obesity, or a pelvic tumor. Excessive flatus or increased peristalsis can cause the perception of quickening. Breast changes can be related to hyperprolactinemia induced by tranquilizers, infection, prolactin-secreting pituitary tumor, pseudocyesis, or premenstrual syndrome. Abdominal enlargement can result from ascites, obesity, or uterine or pelvic tumor, and the perception of Braxton Hicks contractions can result from hematometra or a uterine tumor.

A 28-year-old woman gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus? 1. Soft, at the level of the umbilicus 2. Firm, ¾" (2 cm) below the umbilicus 3. Firm, at the level of the umbilicus 4. Boggy, midway between the umbilicus and symphysis pubis

3. Firm, at the level of the umbilicus Within 1 hour after delivery, the fundus should be firm and at the level of the umbilicus. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage.

A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as: 1. Scant 2. Light 3. Heavy 4. Excessive

3. Heavy Lochia is the discharge from the uterus in the postpartum period that consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (< 1 inch) on menstrual pad in 1 hour ; light = less than 10 cm (< 4 inches) on menstrual pad in 1 hour ; moderate = less than 15 cm (< 6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.

A pregnant client tells a nurse that she has been craving "unusual foods." The nurse gathers additional assessment data from the client and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed on the client. The nurse reviews the results and determines that which of the following indicates a physiological consequence of the client's practice? 1. Hematocrit 38% 2. Glucose 86 mg/ dL 3. Hemoglobin 9.1 g/ dL 4. White blood cell count 12,400/mm3

3. Hemoglobin 9.1 g/ dL Pica cravings often lead to iron deficiency anemia, resulting in a decreased hemoglobin level. The laboratory values in options 1, 2, and 4 are normal for the pregnant client.

A woman in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition? 1. Morning sickness 2. Eclampsia 3. Hyperemesis gravidarum 4. Hydramnios

3. Hyperemesis gravidarum Hyperemesis gravidarum differs from the nausea and vomiting (morning sickness) that normally occur during pregnancy. It's characterized by excessive vomiting that can lead to dehydration and starvation. Without treatment, metabolic changes can lead to severe complications, even death, of the fetus or mother. Eclampsia is the most serious form of pregnancy-induced hypertension. It's characterized by hypertension, seizures, coma, edema, and proteinuria. Hydramnios is an overproduction of amniotic fluid that causes uterine distension.

The nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic response to cold stress? 1. Arrhythmia 2. Hyperglycemia 3. Hypoglycemia 4. Hypertension

3. Hypoglycemia Hypoglycemia, not hyperglycemia, occurs as a result of cold stress. When a neonate is exposed to a cold environment his metabolic rate increases as his body attempts to warm itself. The increase in metabolic rate causes glucose consumption resulting in hypoglycemia. Arrhythmia and hypertension are associated with cardiopulmonary problems.

During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. Which nursing diagnosis is most appropriate for this client? 1. Activity intolerance related to decreased tissue oxygenation 2. Risk for infection related to metabolic and vascular abnormalities 3. Imbalanced nutrition: Less than body requirements related to limited food intake 4. Impaired gas exchange related to respiratory effects of substance abuse

3. Imbalanced nutrition: Less than body requirements related to limited food intake A substance abuser may spend more money on drugs than on food and other basic needs, leading to a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to limited food intake. Activity intolerance might be a relevant nursing diagnosis if the client were having trouble sleeping or getting adequate rest; however, activity intolerance wouldn't be related to decreased tissue oxygenation in this case. If the client were an I.V. drug abuser, a diagnosis of Risk for infection related to I.V. drug use might be appropriate. Because the question doesn't specify how the client is using cocaine, a diagnosis of Impaired gas exchange related to respiratory effects of substance abuse is inappropriate.

A nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? 1. Lethargy 2. Sleepiness 3. Incessant crying 4. Cuddles when being held

3. Incessant crying A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.

A client with cardiac disease delivers a neonate. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which condition can cause cardiac decompensation? 1. Decreased renal function 2. Increased pain 3. Increased cardiac output 4. Decreased hepatic blood flow

3. Increased cardiac output Cardiac output increases immediately after delivery, as blood that had been diverted to the uterus reenters the central circulation. A client who can't tolerate these postpartum changes may experience cardiac decompensation and heart failure. After delivery, renal function increases as urine production and bladder filling increase. Pain rarely worsens after delivery, although some uterine cramps, breast tenderness, and perineal discomfort may occur. Although hepatic blood flow typically falls to prepregnancy levels after delivery, this doesn't affect cardiac function.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring

3. Increased efficiency of contractions Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, however.

A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds. What should the nurse do next? 1. Continue to monitor the baby for fetal distress. 2. Notify the physician and transfer the mother to labor and delivery for imminent delivery. 3. Inform the physician and prepare for discharge; this client has a reassuring strip. 4. Ask the mother to eat something and return for a repeat test; the results are inconclusive.

3. Inform the physician and prepare for discharge; this client has a reassuring strip. Fetal well-being is determined during a nonstress test by two accelerations occurring within 20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids hasn't been shown to influence the outcome of a nonstress test.

A nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Elevate the client's legs. 2. Determine hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn infant to the client until the feelings of faintness and dizziness have subsided.

3. Instruct the client to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not the most appropriate or helpful action in this situation. Option 2 requires a physician's prescription. Option 4 is unnecessary.

Which medication is considered safe during pregnancy? 1. Aspirin 2. Magnesium hydroxide 3. Insulin 4. Oral antidiabetic agents

3. Insulin Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm.

The nurse is preparing to auscultate fetal heart tones in a pregnant client. Abdominal palpation reveals a hard, round mass under the left side of the rib cage; a softer, round mass just above the symphysis pubis; small, irregular shapes in the right side of the abdomen; and a long, firm mass on the left side of the abdomen. Based on these findings, what is the best place to auscultate fetal heart tones? 1. Right lower abdominal quadrant 2. Right upper abdominal quadrant 3. Left upper abdominal quadrant 4. Left lower abdominal quadrant

3. Left upper abdominal quadrant In this client, abdominal palpation reveals that the fetus is lying in a breech position with its back facing the client's left side. Because fetal heart tones are best heard through the fetus's back, the nurse should place the fetoscope or ultrasound stethoscope in the left upper abdominal quadrant for auscultation. Although placement in other locations might allow auscultation of fetal heart tones, the tones would be less clear.

On her 3rd postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What do these findings suggest? 1. Lochia alba 2. Lochia serosa 3. Localized infection 4. Cervical laceration

3. Localized infection Signs of localized infection include a morbid temperature, chills, malaise, generalized pain or discomfort, and foul-smelling, yellow lochia. Lochia alba (a creamy white, brown, or almost colorless discharge) and lochia serosa (a pinkish serous discharge) are odorless and normal. A cervical laceration causes bright, red vaginal bleeding, edema, and bruising.

On a client's 1st postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority? 1. Reassessing the client in 1 hour 2. Administering oxytocin as prescribed 3. Massaging the uterus gently 4. Notifying the physician or nurse-midwife

3. Massaging the uterus gently If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as prescribed. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.

A baby boy is born 8 weeks premature. At birth, he has no spontaneous respirations but is successfully resuscitated. Within several hours he develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. He's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby's care plan to prevent retinopathy of prematurity? 1. Cover his eyes while receiving oxygen. 2. Keep his body temperature low. 3. Monitor partial pressure of oxygen (PaO2) levels. 4. Humidify the oxygen.

3. Monitor partial pressure of oxygen (PaO2) levels. Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen. Covering the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so that his respiratory distress isn't aggravated.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? 1. Betamethasone 2. Morphine sulfate 3. Naloxone (Narcan) 4. Meperidine hydrochloride (Demerol)

3. Naloxone (Narcan) Opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone (Narcan) is a opioid antagonist , which reverses the effects of opioids and is given for respiratory depression . Morphine sulfate and meperidine hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

A client just had twins. Twin "A" weighs 2,500 g (5 lb, 8 oz), and Twin "B" weighs only 1,900 (4 lb, 3 oz). In addition to routine nursing care, the physician has ordered that Twin "B" be kept in an Isolette to help maintain his temperature. Based on the latest research, the nurse might suggest which intervention in place of using an Isolette to maintain the baby's temperature? 1. Increasing the number of calories to support a stable temperature 2. Wrapping the baby in two blankets with a hat and a monitor for low temperatures 3. Placing the twins in the same crib so the larger baby can keep the smaller baby warm 4. Placing a hot-water bottle in the crib of Twin "B"

3. Placing the twins in the same crib so the larger baby can keep the smaller baby warm The latest research indicates that cobedding twins does much to stabilize the neonates and promotes good adaptation to the extrauterine environment. Twins who are cobedded exhibit less crying and have better wake-sleep patterns than twins kept in separate cribs. Increasing the number of calories is unnecessary as is using a hot water bottle. Applying blankets for extra warmth is appropriate, but recent research acknowledges the greater advantage of cobedding.

A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next? 1. Tell the client that smoking is prohibited in the facility, and that if she smokes again, she'll be discharged. 2. Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close by. 3. Notify the physician and security immediately. 4. Ask the nursing assistant to dispose of the marijuana that the client can't smoke anymore.

3. Notify the physician and security immediately. The nurse should immediately notify the physician and security. The physician must be informed because illegal drugs can interfere with the labor process and affect the neonate after delivery. Moreover, the client might have consumed other illegal drugs. The nurse should also inform security who are specially trained to handle such situations. Most hospitals prohibit smoking. The nurse needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is prohibited. Smoking is dangerous around oxygen and it's fine for the nurse to explain the hazard to the client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be asked to dispose of the marijuana.

When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take? 1. Apply an ice pack to the perineum. 2. Massage the uterus every 15 minutes. 3. Notify the physician. 4. Reassure the client that such bleeding is normal.

3. Notify the physician. The nurse should notify the physician because a continuous flow of bright red blood from the vagina and a firm, contracted uterus indicate laceration of the birth canal. Ice application doesn't slow bleeding. Massage isn't necessary because the client's fundus is firm. Telling the client that bleeding is normal would be misleading and would give her a false sense of security.

An infant received the wrong medication dose. What is the charge nurse's role in following up on the incident? 1. Suggest that the nurse who administered the medication speak to the hospital lawyer. 2. Make sure the nurse has liability insurance. 3. Objectively assess the circumstances surrounding the error. 4. Send the nurse to a medication administration course.

3. Objectively assess the circumstances surrounding the error. The charge nurse should objectively assess the circumstances surrounding the medication administration error. After completing her assessment, the charge nurse should develop a plan with the nurse to prevent future errors. The charge nurse doesn't need to make sure the nurse has liability insurance or suggest that the nurse speak with hospital lawyer until the circumstances surrounding the error are investigated. Nothing suggests that the nurse needs to attend a medication administration course.

While examining a neonate, the nurse discovers developmental hip dysplasia. The nurse anticipates that the neonate will be referred to which specialist for evaluation and treatment? 1. Occupational therapist 2. Pediatric podiatrist 3. Orthopedic surgeon 4. Home health nurse

3. Orthopedic surgeon The neonate will most likely be referred to an orthopedic surgeon who can help correct the defect before the child is ready to walk. An occupational therapist, pediatric podiatrist, and home health nurse aren't trained to care for neonates with developmental hip dysplasia.

When a client develops severe postabortion hemorrhage, the physician prescribes ergonovine (Ergotrate Maleate), 0.2 mg I.V. stat. How should the nurse administer this drug? 1. Over 1 minute, after diluting the dose to a volume of 2.5 ml with normal saline solution 2. Over 5 minutes, after diluting the dose to a volume of 3 ml with dextrose 5% in water 3. Over 1 minute, after diluting the dose to a volume of 5 ml with normal saline solution 4. Over 5 minutes, after diluting the dose to a volume of 5 ml with dextrose 5% in water

3. Over 1 minute, after diluting the dose to a volume of 5 ml with normal saline solution To administer ergonovine to treat severe vaginal bleeding, the nurse dilutes the dose to a volume of 5 ml with normal saline solution and administers it I.V. over 1 minute, while blood pressure and uterine tone are monitored.

A woman in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her uterus is soft, and she's experiencing no pain. Fetal heart rate is 120 beats/minute. Based on the history above, the nurse should suspect which of the following conditions? 1. Abruptio placentae 2. Preterm labor 3. Placenta previa 4. Threatened abortion

3. Placenta previa Placenta previa is associated with painless vaginal bleeding that occurs when the placenta or a portion of the placenta covers the cervical os. In abruptio placentae, the placenta tears away from the wall of the uterus before delivery; the client usually has pain and a boardlike uterus. Preterm labor is associated with contractions and shouldn't involve bright red bleeding. By definition, threatened abortion occurs during the first 20 weeks' gestation.

A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a baby boy. Which priority intervention should be included in the care plan for the baby during his first 24 hours? 1. Administer insulin subcutaneously 2. Administer a bolus of glucose I.V. 3. Provide frequent early feedings with formula. 4. Avoid oral feedings.

3. Provide frequent early feedings with formula. The infant of a diabetic mother may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the infant of a diabetic mother is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia.

Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium? 1. Rubella counseling and immunization with adult measles-mumps-rubella (MMR) vaccine 2. Rubella counseling and immunization with Rho (D) Immune Globulin (RhoGAM) vaccine 3. Rubella counseling and immunization with live rubella virus vaccine 4. Rubella counseling and instruction to obtain live rubella virus vaccine during her first postpartum examination

3. Rubella counseling and immunization with live rubella virus vaccine A client who contracts rubella during pregnancy is at risk for delivering a fetus with severe congenital defects. Therefore, the client should receive rubella counseling and immunization with the live rubella virus vaccine before discharge. Immunization should take place as soon as possible before the client becomes pregnant again. The client should be advised to avoid pregnancy for 3 months after immunization. Rho (D) Immune Globulin is administered to clients who are Rh-negative and come in contact with Rh-positive blood from an Rh-positive fetus.

An obstetric ultrasound reveals that the client's fetus has spina bifida. The mother is concerned about raising a child with a congenital abnormality and she starts to cry. Which response by the nurse is best? 1. Recommend elective termination of the pregnancy. 2. Recommend a pediatrician because the baby will be sick. 3. Sit at her bedside and allow the client to express her feelings. 4. Discuss the risk of dystocia with vaginal births.

3. Sit at her bedside and allow the client to express her feelings. The mother has just been given unexpected news. The nurse should provide emotional support by sitting with the client and allowing her to express her feelings and concerns. The nurse shouldn't tell a client what to do. The client needs information to make her own informed decision. Recommending a pediatrician is premature because the client just received the ultrasound results. The nurse shouldn't discuss birth at this time. The preferred method of delivery with spina bifida is cesarean section, which prevents damage to the open spinal cord defect as the fetus descends through the birth canal.

The nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy? 1. Postterm birth 2. Large size for gestational age 3. Small size for gestational age 4. Appropriate size for gestational age

3. Small size for gestational age Neonates of women who smoked during pregnancy are small for gestational age for two reasons: Nicotine causes vasoconstriction, which reduces blood flow and thus nutrient transfer to the fetus, and smokers are at greater risk for poor nutrition. These neonates are more likely to be preterm than postterm because smoking causes maternal vasoconstriction, decreases placental perfusion, and induces uterine contractions. Large size for gestational age results from increased nutrient transfer to the fetus such as in a neonate who receives excessive glucose from a diabetic mother.

One minute after birth, a neonate has an Apgar score of 7. What should the nurse do? 1. Administer oxygen via nasal prongs as ordered. 2. Begin cardiopulmonary resuscitation (CPR). 3. Stimulate breathing by rubbing the neonate's back. 4. Encourage the mother to hold the neonate close.

3. Stimulate breathing by rubbing the neonate's back. An Apgar score of 5 to 7 (out of a total possible score of 10) indicates mild respiratory depression. To correct this problem, the nurse should stimulate breathing by rubbing the neonate's back or by gently but firmly slapping the neonate's soles. The nurse should also provide oxygen (at 100% concentration) but should administer it by bag and face mask rather than nasal prongs. The nurse should perform CPR only if the neonate's Apgar score is between 0 and 2. The neonate must be stabilized before being held by the mother.

How does the nurse assess the rooting reflex of a neonate? 1. Placing an object in the neonate's palm 2. Stroking the sole of the neonate's foot 3. Stroking the neonate's cheek 4. Touching the neonate's lips

3. Stroking the neonate's cheek The rooting reflex is elicited by stroking the neonate's cheek or stroking near the corner of the neonate's mouth. The neonate turns the head in the direction of the stroking, looking for food. This reflex disappears by 6 weeks. Other options refer to other reflexes seen in neonates: The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonate's fingers close around it. This reflex disappears between ages 6 and 9 months. The Babinski reflex is elicited by stroking the neonate's foot, on the side of the sole, from the heel toward the toes. A neonate will fan his toes, producing a positive Babinski sign, until about age 3 months. The sucking reflex is seen when the neonate's lips are touched and lasts for about 6 months.

To promote comfort during labor, the nurse advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia? 1. Lateral position 2. Squatting position 3. Supine position 4. Standing position

3. Supine position The supine position causes compression of the client's aorta and inferior vena cava by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle.

The nurse is caring for a postpartum mother suspected of developing postpartum psychosis. Which of the following statements accurately characterize this disorder? 1. Symptoms start 2 days after delivery. 2. The disorder is common in postpartum women. 3. Symptoms include delusions and hallucinations. 4. Suicide and infanticide are uncommon in this disorder. 5. The disorder rarely occurs without psychiatric history.

3. Symptoms include delusions and hallucinations. 5. The disorder rarely occurs without psychiatric history. A postpartum woman should be suspected of psychosis if she exhibits manic-depressive behaviors (delusions or hallucinations), generally starting within 4 weeks postpartum. Typically, the woman has a past history of a psychiatric disorder and treatment. The disorder occurs in less then 1% of postpartum mothers. It's considered a medical emergency. Suicide and infanticide are common.

A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps? 1. Suggesting that she walk for 1 hour twice per day 2. Advising her to take over-the-counter calcium supplements twice per day 3. Teaching her to dorsiflex her foot during the cramp 4. Instructing her to increase milk and cheese intake to 8 to 10 servings per day

3. Teaching her to dorsiflex her foot during the cramp Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours daily during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a well-balanced diet, calcium supplements and additional servings of high-calcium foods may be unnecessary.

A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following assessments is noted? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid.

3. The cervix is dilated completely. The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

A client, age 22, is a gravida 1, para 0. During the first 24 hours after delivery, she doesn't show consistent interest in her neonate. How should the nurse interpret her behavior? 1. The client is experiencing postpartum depression. 2. The client is questioning her role as a mother. 3. The client is showing expected behaviors for the taking-in period. 4. The client is failing to attach to the neonate.

3. The client is showing expected behaviors for the taking-in period. According to Rubin, dependence and passivity are typical during the taking-in period, which may last up to 3 days after delivery. A client experiencing postpartum depression demonstrates anxiety, confusion, or other signs and symptoms consistently. Maternal role attainment occurs over 3 to 10 months. Attachment also is an ongoing process that occurs gradually.

Infertility in a 25-year-old couple is defined as which of the following? 1. The couple's inability to conceive after 6 months of unprotected attempts 2. The couple's inability to sustain a pregnancy 3. The couple's inability to conceive after 1 year of unprotected attempts 4. A low sperm count and decreased motility

3. The couple's inability to conceive after 1 year of unprotected attempts The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse.

The nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which of the following as the main advantage of this method? 1. The implants can be removed easily if pregnancy occurs. 2. The implants cost less over the long term than other contraceptive methods. 3. The implants provide effective, continuous contraception that isn't user dependent. 4. The implants require a lower hormonal dose than other hormonal contraceptive methods.

3. The implants provide effective, continuous contraception that isn't user dependent. Although all of the options accurately describe features of subdermal contraceptive implants, the main advantage of this contraceptive method is effective, continuous contraception that isn't user dependent. The effectiveness of other methods, such as the condom, diaphragm, and oral contraceptives, depends at least partly on the user's knowledge, skills, and motivation.

The nurse is doing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero? 1. The neonate grasps the nurse's finger when she puts it in the palm of his hand. 2. The neonate does stepping movements when held upright with sole of foot touching a surface. 3. The neonate's toes don't curl downward when soles of feet are stroked. 4. The neonate doesn't respond when the nurse claps her hands above him. 5. The neonate turns toward the nurse's finger when she touches his cheek. 6. The neonate displays weak, ineffective sucking.

3. The neonate's toes don't curl downward when soles of feet are stroked. 4. The neonate doesn't respond when the nurse claps her hands above him. 6. The neonate displays weak, ineffective sucking. If the neonate's toes don't curl downward when the soles of his feet are stroked and he doesn't respond to a loud sound, it may be evidence that neurologic damage from asphyxia has occurred. A normal neurologic response would be the toes curling downward with stroking and extending arms and legs with a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate should grasp a person's finger when it's placed in the palm of his hand, do stepping movements when held upright with the sole of foot touching a surface, and turn toward the nurse's finger when she touches his cheek.

A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. Why should the nurse apply manual pressure to the baby's head? 1. To slow the delivery process 2. To reinsert the umbilical cord 3. To relieve pressure on the umbilical cord 4. To rupture the membranes

3. To relieve pressure on the umbilical cord Manual pressure is applied to the baby's head by gently pushing up with the fingers to relieve pressure on the umbilical cord. This intervention is effective if the cord begins to pulsate. The mother may also be placed in either the knee-chest or Trendelenburg position to ensure blood flow to the baby. This intervention isn't done to slow the delivery process. A prolapsed cord necessitates emergency cesarean section. The nurse shouldn't attempt to reinsert the umbilical cord because this would further compromise blood flow. At this point, the membranes are probably ruptured.

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean delivery? 1. Insufficient perineal stretching 2. Rapid, progressive labor 3. Umbilical cord prolapse 4. Fetal prematurity

3. Umbilical cord prolapse Indications for cesarean delivery include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean delivery, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. Insufficient perineal stretching; rapid, progressive labor; and fetal prematurity aren't indications for cesarean delivery.

The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (89 ml) or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find? 1. Prominent nasal bridge 2. Thick upper lip 3. Upturned nose 4. Large for gestational age

3. Upturned nose Babies born with fetal alcohol syndrome have upturned noses, flattened nasal bridges, and a thin upper lip. They may also be small for gestational age.

After several hours of using music and imagery to promote comfort, a client in labor becomes discouraged and frustrated. What should the nurse suggest? 1. Continue to use these methods until they work. 2. Ask the support person to leave the room temporarily. 3. Use an alternate method of promoting comfort. 4. Encourage the client to get some sleep.

3. Use an alternate method of promoting comfort. If a client becomes discouraged or frustrated during labor, the nurse should reassure her and help her choose an alternate method of promoting comfort. The other options would increase the client's frustration.

A client in the early stages of labor is admitted to the labor and delivery unit. During the admission assessment, the client fails to make eye contact with the nurse. The nurse notes ecchymotic areas on the client's thighs and forearms. The husband is present at the client's bedside. The nurse suspects domestic abuse, how should she respond? 1. Ask the client if her husband is abusing her. 2. Efficiently complete the admission paperwork. 3. When the husband leaves the room, ask the client if she ever feels unsafe at home. 4. Notify the local police.

3. When the husband leaves the room, ask the client if she ever feels unsafe at home. The client's failure to make eye contact and the presence of ecchymosis on her thighs and forearms should alert the nurse that the client might be a victim of abuse. The nurse should respond by asking the client if she ever feels unsafe at home. This questioning should take place when the husband leaves the room. Option 1 is accusatory. The husband may not be abusing the client. Option 2 doesn't address the suspected abuse. The nurse must further explore the situation before notifying the proper authorities of the suspected abuse.

A client, age 19, has an episiotomy to widen her birth canal. Delivery extends the incision into the anal sphincter. This complication is called: 1. a first-degree laceration. 2. a second-degree laceration. 3. a third-degree laceration. 4. a fourth-degree laceration.

3. a third-degree laceration. Delivery may extend an episiotomy incision to the anal sphincter (a third-degree laceration) or the anal canal (a fourth-degree laceration). A first-degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second-degree laceration extends to the fasciae and muscle of the perineal body.

A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the: 1. subarachnoid space. 2. area between the subarachnoid space and the dura mater. 3. area between the dura mater and the ligamentum flavum. 4. ligamentum flavum.

3. area between the dura mater and the ligamentum flavum. For an epidural block, the nurse should anticipate that the anesthesiologist will inject a local anesthetic agent into the epidural space, located between the dura mater and the ligamentum flavum in the lumbar region of the spinal column. When administering a spinal block, the anesthesiologist injects the anesthetic agent into the subarachnoid space. The ligamentum flavum and the area between the subarachnoid space and the dura mater are inappropriate injection sites.

A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to: 1. use an electric breast pump. 2. apply warm, moist compresses to the breasts. 3. breast-feed as often as the infant is hungry — typically every 1 to 3 hours. 4. wear a brassiere 24 hours per day.

3. breast-feed as often as the infant is hungry — typically every 1 to 3 hours. Frequent breast-feeding empties the breasts and increases circulation, helping to remove fluid that may lead to engorgement. If the infant isn't ill or physically impaired and can breast-feed, the client shouldn't use an electric breast pump because this deprives the infant of optimal sucking and skin-to-skin contact with the mother. Applying warm, moist compresses stimulates the let-down reflex and causes the breasts to fill, which may lead to engorgement. A brassiere supports the breasts but doesn't prevent engorgement unless the client breast-feeds frequently.

A postpartum client plans to breast-feed her first child, a full-term neonate. She asks the nurse, "How will I know if my baby is getting enough to eat?" The nurse informs her that nutritional intake is adequate if the neonate: 1. wets 6 to 8 diapers in 24 hours. 2. shows a desire to be fed every 1 to 2 hours. 3. exhibits a steady weight gain. 4. burps after a feeding.

3. exhibits a steady weight gain. Signs that a neonate is getting adequate intake include exhibiting a steady weight gain, wetting 10 to 12 diapers in 24 hours, and showing contentedness after a feeding. Wetting 6 to 8 diapers in 24 hours signifies inadequate intake. Wanting to be fed every 1 to 2 hours indicates that the neonate isn't satiated. Burping after a feeding isn't associated with feeding adequacy.

A client who's 7 weeks pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client's care, the nurse anticipates informing her that if she doesn't stop smoking, her fetus will develop: 1. a neural tube defect. 2. a cardiac abnormality. 3. intrauterine growth retardation. 4. a renal disorder.

3. intrauterine growth retardation. The risk of intrauterine growth retardation may increase with the number of cigarettes a pregnant woman smokes. Neural tube defects, cardiac abnormalities, and renal disorders are associated with multifactorial genetic inheritance, not maternal cigarette smoking.

The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: 1. peripheral acrocyanosis. 2. bradycardia. 3. lethargy. 4. jaundice.

3. lethargy. Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.

A multiparous client is admitted to the labor and delivery area with painless vaginal bleeding. Ultrasonography shows that an edge of her placenta meets but doesn't occlude the rim of the cervical os. This finding suggests: 1. partial placenta previa. 2. a low-lying placenta. 3. marginal placenta previa. 4. abruptio placentae.

3. marginal placenta previa. Marginal placenta previa is present when the edge of the placenta meets the rim of the cervical os but doesn't occlude it. In partial placenta previa, the placenta covers the os partially. In a low-lying placenta, the placenta implants in the lower uterine segment and a placental edge lies close to the cervical os. In abruptio placentae, the placenta separates from the uterine wall.

During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a precipitous delivery by: 1. applying counterpressure to the fetus's head. 2. encouraging the client to push. 3. massaging and supporting the perineum. 4. instructing the client to contract the perineal muscles.

3. massaging and supporting the perineum. The nurse can help control a precipitous delivery by stretching the labia, such as by massaging and bracing the perineum with gentle back pressure. This helps prevent perineal lacerations — the primary maternal complication of precipitous delivery. Applying counterpressure to the fetus's head reduces perineal stress temporarily; however, delivery proceeds when the client pushes with uterine contractions. Pushing puts further stress on the perineum, promoting delivery. When the fetus's head exerts pressure on the perineum, contracting the perineal muscles is virtually impossible.

It's difficult to awaken a neonate 3 hours after birth. The nurse recognizes that this behavior indicates: 1. a physiologic abnormality. 2. probable hypoglycemia. 3. normal progression into the sleep cycle. 4. normal progression into a period of neonatal reactivity.

3. normal progression into the sleep cycle. Typically, it's difficult to awaken any neonate 3 hours after birth. This finding suggests normal progression into the sleep cycle. During this period, the neonate shows minimal response to external stimuli. Hypoglycemia is characterized by irregular respirations, apnea, and tremors. Periods of neonatal reactivity are characterized by alertness and attentiveness.

The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity: 1. develops rapidly and is temporary. 2. occurs by antibody transmission. 3. results from exposure of an antigen through immunization or disease contact. 4. may be transferred by mother to neonate.

3. results from exposure of an antigen through immunization or disease contact. Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but it's temporary. Passive immunity may be transferred by mother to neonate.

A neonate weighing 1 lb 8.7 oz (700 g) is born at 30 weeks' gestation, as determined by the Ballard examination. Based on her weight and gestational age, she falls below the 10th percentile on the Colorado intrauterine growth chart. The nurse concludes that she's: 1. appropriate for gestational age. 2. large for gestational age. 3. small for gestational age. 4. average in birth weight.

3. small for gestational age. A neonate whose weight falls below the 10th percentile on the Colorado intrauterine growth chart is small for gestational age. One whose weight falls between the 10th and 90th percentiles is appropriate for gestational age. One whose weight falls above the 90th percentile is large for gestational age. The Colorado intrauterine growth chart doesn't include criteria to identify an average birth weight.

A client says she wants to practice natural family planning. The nurse teaches her how to use the calendar method to determine when she's fertile and advises her to avoid unprotected intercourse. When teaching her how to determine her fertile period, the nurse should instruct her to: 1. abstain from unprotected intercourse between days 14 and 16 of the menstrual cycle. 2. subtract 11 days from her shortest menstrual cycle and 18 days from her longest cycle. 3. subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle. 4. add 25 days to the 1st day of her last menstrual period and abstain from unprotected intercourse for the next 5 days.

3. subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle. To determine the fertile period, the client should subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle; if she doesn't wish to become pregnant, she should abstain from unprotected intercourse between the days calculated. For example, if her menstrual cycles range from 28 to 30 days, her fertile period encompasses days 10 to 19 of her cycle. Abstaining from unprotected intercourse on certain days (option 1) doesn't determine the fertile period; also, for most women, abstaining on days 14 through 16 wouldn't be sufficient to cover the entire fertile period. Options 2 and 4 are incorrect applications of the calendar method.

While talking to the nurse, the parents of a neonate in the neonatal intensive care unit (NICU) express concern that they're neglecting their 3-year-old son. The nurse suggests a sibling visit. To best promote the sibling's attachment to the neonate, the nurse should: 1. provide the sibling with detailed information about the neonate's condition when he visits the NICU. 2. explain to the sibling how family life will change when the neonate goes home. 3. suggest that the sibling bring in a drawing to display near the neonate's crib in the NICU. 4. discuss ways in which the sibling can participate in the neonate's care.

3. suggest that the sibling bring in a drawing to display near the neonate's crib in the NICU. To help a sibling develop an attachment to the neonate, the nurse should suggest that the sibling contribute an item to the neonate's environment, such as a drawing or toy. Providing detailed information and explaining how family life will change are too overwhelming and confusing for any sibling, especially a 3-year-old. Because of the neonate's status, discussing ways for the sibling to participate in neonatal care is inappropriate.

A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: 1. milk and ice pops. 2. decaffeinated coffee and scrambled eggs. 3. tea and gelatin dessert. 4. apple juice and oatmeal.

3. tea and gelatin dessert. A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet.

A client asks how long she and her husband can safely continue sexual activity during pregnancy. How should the nurse respond? 1. "Until the end of the first trimester" 2. "Until the end of the second trimester" 3. "Until the end of the third trimester" 4. "As long as you wish, if the pregnancy is normal"

4. "As long as you wish, if the pregnancy is normal" During a normal pregnancy, the client and her partner need not discontinue sexual activity. If the client develops complications that could lead to preterm labor, she and her partner should consult with a health practitioner for advice on the safety of sexual activity.

A client, 2 months pregnant, has hyperemesis gravidarum. Which expected outcome is most appropriate for her? 1. "Client will accept the pregnancy and stop vomiting." 2. "Client will gain weight according to the expected pattern for pregnancy." 3. "Client will remain hospitalized for the duration of pregnancy to relieve stress." 4. "Client will exhibit uterine growth within the expected norms for gestational age."

4. "Client will exhibit uterine growth within the expected norms for gestational age." For a client with hyperemesis gravidarum, the goal of nursing care is to achieve optimal fetal growth, which can be evaluated by monitoring uterine growth through fundal height assessment. The nurse shouldn't assume that excessive vomiting signifies the client doesn't accept the pregnancy. Clients with hyperemesis gravidarum rarely gain weight according to the expected pattern. They may be hospitalized briefly to regulate fluid and electrolyte status, but they don't require hospitalization for the duration of pregnancy. In fact, hospitalization may add to the stress of pregnancy by causing family separation and financial concerns.

The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform molar pregnancy. Which expected outcome takes highest priority for this client? 1. "Client will state that she may attempt another pregnancy after 3 months of follow-up care." 2. "Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge." 3. "Client will state that she won't attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises." 4. "Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."

4. "Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative." After a molar pregnancy, the client should receive follow-up care, including regular hCG testing, for 1 year because of the risk of developing chorionic carcinoma. After removal of a hydatidiform mole, the hCG level gradually falls to a negative reading unless chorionic carcinoma is developing, in which case the hCG level rises. A Pap test isn't an effective indicator of a hydatidiform molar pregnancy. A follow-up examination would be scheduled within weeks of the client's discharge. The client must not become pregnant during follow-up care because pregnancy causes the hCG level to rise, making it indistinguishable from this early sign of chorionic carcinoma.

A client who's planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. Which of the following would be the nurse's best response? 1. "Pregnancy is a human process; you don't have to worry." 2. "You practice good health habits; just follow them and you'll be fine." 3. "There is nothing you can do to have a healthy pregnancy; it's all up to nature." 4. "Folic acid, 400 mcg, improves pregnancy outcomes by preventing certain complications."

4. "Folic acid, 400 mcg, improves pregnancy outcomes by preventing certain complications." When counseling a client who's planning to become pregnant, the nurse should discuss the role of folic acid in preventing neural tube defects. The nurse should provide information but not prescribe the drug. It's the client's responsibility to ask the health care provider about a prescription. Telling the client not to worry ignores the client's needs. Telling the client that it's up to nature is inaccurate. Practicing good health habits is important for any person.

An adolescent client with ruptured membranes is admitted to the hospital. A few hours after her arrival to the labor and delivery unit, the client's high school principal calls to inquire about her condition. How should the nurse respond? 1. "She most likely won't deliver for another 15 hours." 2. "She hasn't delivered her baby yet." 3. "I'll call you when she delivers." 4. "For confidentiality reasons, I can't give you any information."

4. "For confidentiality reasons, I can't give you any information." The nurse should respond by telling the principal that for confidentiality reasons she can't provide any information about the client's condition. Options 1, 2, and 3 breech client confidentiality.

A clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? 1. "I should avoid between-meal snacks." 2. "I should lie down for an hour after eating." 3. "I should use spices for cooking rather than using salt." 4. "I should avoid eating foods that produce gas, such as beans and some vegetables, and fatty foods such as deep-fried chicken."

4. "I should avoid eating foods that produce gas, such as beans and some vegetables, and fatty foods such as deep-fried chicken." Lying down is likely to lead to reflux of stomach contents, especially immediately after a meal. The client should be instructed to avoid spices, along with salt, because spices trigger heartburn. Salt produces edema. The client should be encouraged to eat between-meal snacks and should be instructed that to control heartburn, eating smaller, more frequent portions is preferred over eating three large meals. The client also should limit or avoid gas-producing and fatty foods.

A registered nurse is staff-shared to the maternal-neonatal unit where she has never worked before. How can this nurse be best employed? 1. Assign her to the labor and delivery area. 2. Assign her to the nursery. 3. Use her as a nursing assistant in the postpartum unit. 4. Assign her a client care assignment in the postpartum unit.

4. Assign her a client care assignment in the postpartum unit. The staff-shared nurse can be best employed in client care in the postpartum unit because such an assignment requires medical-surgical knowledge. In this setting, the nurse can safely use her nursing skills and doesn't need to assume the role of a nursing assistant. The staff-shared nurse isn't qualified to work in the labor and delivery area or the nursery because both require specialized training to safely administer care.

A nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I should increase my sodium intake during pregnancy." 2. "I should lower my blood volume by limiting my fluids." 3. "I should maintain a low-calorie diet to prevent any weight gain." 4. "I should drink adequate fluids and increase my intake of high-fiber foods."

4. "I should drink adequate fluids and increase my intake of high-fiber foods." Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can cause the client to use Valsalva maneuver. High-fiber foods are important. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients, so adequate fluid intake and high-fiber foods are important. Sodium should be restricted as prescribed by the physician because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications.

The nurse determines that a new mother understands the teaching about prevention of newborn abduction if she states: 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "It's OK to allow the nurse assistant to carry my newborn to the nursery." 4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."

4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking a nurse to attend to the newborn if the mother is napping and no family member is available to watch the newborn (the newborn is never left unattended). If the mother states that she will ask the nurse to watch the newborn while she is sleeping, she has understood the teaching. Options 1, 2, and 3 are incorrect and would indicate that the mother needs further teaching.

The nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching? 1. "I'll use massage to help soften my breasts." 2. "I'll use warm packs or a warm shower to ease engorgement." 3. "If the baby feeds only on one side, I'll express milk from the other side." 4. "If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."

4. "If my breasts are uncomfortable, I'll limit the time I spend breast-feeding." Engorgement results from fullness in breast veins and alveolar engorgement with milk. Limiting the time spent breast-feeding causes insufficient breast milk removal; as a result, milk volume exceeds alveolar storage capacity, causing pain. Breast massage, heat application, and milk expression help minimize engorgement.

A nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

4. "My contractions will increase in duration and intensity."

A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary caregiver? 1. Breast tenderness 2. Breakthrough bleeding within first 3 months of use 3. Decreased menstrual flow 4. Blurred vision and headache

4. Blurred vision and headache Some adverse effects of birth control pills, such as blurred vision and headaches, require a report to the health care provider. Because these two effects in particular may result in cardiovascular compromise and embolus, the client may need to use another form of birth control. Breast tenderness, breakthrough bleeding, and decreased menstrual flow may occur as a normal response to the use of birth control pills.

The nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron? 1. A glass of milk 2. A cup of hot tea 3. A liquid antacid 4. A glass of orange juice

4. A glass of orange juice Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron.

On her second visit to the prenatal facility, a client states, "I guess I really am pregnant. I've missed two periods now." Based on this statement, the nurse determines that the client has accomplished which psychological task of pregnancy? 1. Identifying the fetus as a separate being 2. Assuming caretaking responsibility for the neonate 3. Preparing to relinquish the neonate through labor 4. Accepting the biological fact of pregnancy

4. Accepting the biological fact of pregnancy The first maternal psychological task of pregnancy is to accept the pregnancy as a biological fact. If the client doesn't accept that she's pregnant, she's unlikely to seek prenatal care. Identifying the fetus as a separate being usually occurs after the client feels fetal movements. Assuming caretaking responsibility for the neonate should occur during the postpartum period. Preparing to relinquish the neonate through labor normally occurs during the third trimester.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which of the following would be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/ min, by face mask.

4. Administer oxygen, 8 to 10 L/ min, by face mask. Rationale: If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/ min, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bedrest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which of the following actions would be inappropriate in managing the client's breast engorgement? 1. Applying frozen cabbage leaves to the breasts 2. Encouraging the client to shower with her back to the water 3. Encouraging the client to nurse her baby frequently 4. Applying a breast binder to support the breasts

4. Applying a breast binder to support the breasts Engorgement in a breast-feeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Binding the breasts isn't appropriate because the constriction will diminish the milk supply. Frozen cabbage leaves work well to reduce the pain and swelling and should be applied every 4 hours. Facing the shower head can stimulate the breasts and intensify the problem. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant.

A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents? 1. Ask the community health nurse to visit the family. 2. Provide written care instructions for the parents. 3. Help the parents schedule a follow-up appointment with the pediatrician before discharge. 4. Arrange a meeting between the health care team and the parents to develop a care plan.

4. Arrange a meeting between the health care team and the parents to develop a care plan. A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge.

A neonate begins to gag and turns a dusky color. What should the nurse do first? 1. Calm the neonate. 2. Notify the physician. 3. Provide oxygen via a face mask as ordered. 4. Aspirate the neonate's nose and mouth with a bulb syringe.

4. Aspirate the neonate's nose and mouth with a bulb syringe. The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician. Administering oxygen when the airway isn't clear would be ineffective.

For a client who's fully dilated, which of the following actions would be inappropriate during the second stage of labor? 1. Positioning the mother for effective pushing 2. Preparing for delivery of the baby 3. Assessing vital signs every 15 minutes 4. Assessing for rupture of membranes

4. Assessing for rupture of membranes In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor. Positioning for effective pushing, preparing for delivery, and assessing vital signs every 15 minutes are appropriate actions at this time.

A nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, in abruptio placentae, the abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability.

A client has progressed through the first stage of labor. Which assessment finding suggests she's in the transition to the second stage? 1. A decreased urge to push 2. Decreased bloody show 3. Fetal heart rate (FHR) accelerations 4. Bulging of the vaginal introitus

4. Bulging of the vaginal introitus Signs and symptoms of transition to the second stage of labor include bulging of the vaginal introitus, an increased urge to push, increased bloody show, and grunting. FHR accelerations may occur at any time during labor.

Which circumstance is not a contributing factor to unstable blood sugars in the neonate? 1. Prematurity 2. Respiratory distress 3. Postdated infant 4. Cesarean section delivery

4. Cesarean section delivery Neonates delivered by cesarean section without any other contributing factors should have adequate stores of brown fat to control blood glucose levels. Stores of brown fat aren't deposited until 36 weeks, so neonates born at less than 36 weeks won't have the necessary stores to maintain a normal blood glucose level. Neonates who are postdated or have respiratory distress will use up their stores of brown fat as a result of these complications.

A client delivers a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's husband seems withdrawn and barely speaks to the staff when visiting his child in the NICU. His behavior indicates that he's in which stage of grief? 1. Denial 2. Anger 3. Bargaining 4. Depression

4. Depression During the depression stage of grief, hopelessness, powerlessness, and despair are common. Some depressed people put their feelings into words; others withdraw, becoming noncommunicative and indicating a wish to be left alone. A parent in denial would postpone recognizing the child's condition and attempt to ignore its reality or seriousness. A parent in the anger stage would exhibit resentment, bitterness, or rage and might blame the health care team for the child's condition. A parent in the bargaining stage would be willing to do anything that might help the child or delay perinatal loss.

Umbilical cord prolapse necessitated cesarean delivery of a preterm, low-birth-weight neonate. Immediately after delivery, the neonate is limp, gasping for air, unresponsive to stimulation, and has blue discoloration of the face, lips, and torso. Which intervention should the nursery nurse perform first? 1. Establish I.V. access through an umbilical venous catheter. 2. Initiate cardiac compressions. 3. Administer low-flow oxygen through a nasal cannula. 4. Determine unresponsiveness and assess the need for resuscitation.

4. Determine unresponsiveness and assess the need for resuscitation. The nurse should determine unresponsiveness and assess the need for resuscitation. If resuscitation is necessary, the nurse should initiate it immediately. After addressing airway, breathing, and circulation the nurse should establish I.V. access. Oxygen should be administered through a bag-valve mask, not a nasal cannula. It may be necessary to begin cardiac compressions depending upon the neonate's heart rate.

A client in labor is receiving oxytocin (Pitocin). The electronic fetal monitoring strip shows contractions occurring every 30 seconds to 2 minutes, with an intensity of 90 mm Hg and increasing resting tone. How should the nurse respond to these findings? 1. Administer oxygen as prescribed. 2. Call the physician. 3. Check the fetal heart rate (FHR). 4. Discontinue the oxytocin infusion.

4. Discontinue the oxytocin infusion. Oxytocin should be discontinued when contractions occur less than 2 minutes apart or last longer than 90 seconds. The nurse can stop oxytocin infusion independently without seeking permission from the physician — an action that would waste valuable time. This client isn't oxygen deprived and, therefore, doesn't need supplemental oxygen. Checking the FHR isn't appropriate in this situation because the decelerations occur and resolve with each contraction, independent of oxytocin administration.

The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her baby? 1. Encourage breast-feeding so that she can get her rest and get healthier. 2. Encourage breast-feeding because it's healthier for the baby. 3. Encourage breast-feeding to facilitate bonding. 4. Discourage breast-feeding because HIV can be transmitted through breast milk.

4. Discourage breast-feeding because HIV can be transmitted through breast milk. Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case.

A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is appropriate? 1. Notify the physician or nurse-midwife of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bedrest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve . Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary.

During assessment for admission to the labor and delivery area, a client and her husband ask the nurse whether their sons, ages 8 and 10, can witness the childbirth. Before answering this question, the nurse should consider which guideline? 1. The children and client should share a support person during the childbirth. 2. Children should attend childbirth only if it takes place at home. 3. Children shouldn't attend childbirth because it will frighten them. 4. Each child attending the childbirth should have a separate support person.

4. Each child attending the childbirth should have a separate support person. Each child attending the childbirth should have a support person — one who isn't also serving as the client's support person. The support person explains what is happening, reassures the child, and removes the child from the area if an emergency occurs or if the child becomes frightened. Children can attend childbirth in any setting. The decision to have a child present hinges on the child's developmental level, ability to understand the experience, and amount of preparation.

The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? 1. Administer ephedrine to raise her blood pressure. 2. Administer oxygen using a mask. 3. Place the woman supine with her legs raised. 4. Ensure adequate hydration before the anesthetic is administered.

4. Ensure adequate hydration before the anesthetic is administered. Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can contribute to hypotension because of uterine pressure on the great vessels.

A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura

4. Evidence of bleeding, such as in the gums, petechiae, and purpura Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

A client who's 2 months pregnant complains of urinary frequency and says she gets up several times at night to go to the bathroom. She denies other urinary symptoms. How should the nurse intervene? 1. Advise the client to decrease her daily fluid intake. 2. Refer the client to a urologist for further investigation. 3. Explain that urinary frequency isn't a sign of urinary tract infection (UTI). 4. Explain that urinary frequency is expected during the first trimester.

4. Explain that urinary frequency is expected during the first trimester. Urinary frequency is expected during the first trimester as the growing uterus exerts pressure on the client's bladder. Although the client should increase fluid intake during pregnancy, she should avoid drinking fluids after 6 p.m. to reduce the need to get up at night. Because urinary frequency is a normal discomfort of pregnancy and the client has no other signs or symptoms of UTI, referral to a urologist is unnecessary. Urinary frequency, dysuria, and voiding of small amounts of urine indicate UTI.

A client's husband asks to read his wife's medical record. He claims to be a nursing student and that reading it would be a learning opportunity. What action by the nurse is most appropriate? 1. Review the medical record with the husband and teach him documentation principles. 2. Have the husband review the medical record in the presence of the nursing staff. 3. Tell the husband that he made a wise choice in choosing the nursing profession and allow him to review the record. 4. Explain that, for client confidentiality reasons, he can't review the medical record.

4. Explain that, for client confidentiality reasons, he can't review the medical record. The nurse should explain that for confidentiality reasons he can't review the medical record. Some facilities permit family members to review the client's medical records in the presence of staff, but only with the client's permission and a physician's order.

A client who's 3 months pregnant with her first child reports that she has had increasing morning sickness for the past month. Nursing assessment reveals a fundal height of 20 cm and no audible fetal heart tones. The nurse should suspect which complication of pregnancy? 1. Fetal demise 2. Ectopic pregnancy 3. Hyperemesis gravidarum 4. Gestational trophoblastic disease

4. Gestational trophoblastic disease Gestational trophoblastic disease causes increased nausea and vomiting, uterine enlargement beyond that expected for the number of weeks' gestation, absence of fetal heart tones, and vaginal spotting. Because the client exhibits most of these signs, she requires further evaluation. In fetal demise, uterine size decreases; the client's fundal height of 20 cm at 3 months' gestation is too large to indicate fetal demise. Absence of fetal heart tones is a sign of ectopic pregnancy; however, a fundal height of 20 cm doesn't support that diagnosis. Although hyperemesis gravidarum causes increased nausea and vomiting, the client's enlarged uterus suggests a different problem.

The nurse is preparing to perform a physical examination on a postpartum client. Which statement best explains why the nurse must wear latex gloves during this examination? 1. Gloves may protect the client against infectious organisms. 2. Gloves guard the client against the nurse's cold hands. 3. Gloves may protect the nurse against infectious organisms. 4. Gloves are required for standard precautions.

4. Gloves are required for standard precautions. Wearing gloves whenever exposure to blood or body fluids is anticipated is a standard precaution recommended by the Centers for Disease Control and Prevention. Although gloves protect both the client and the nurse from infectious organisms and guard against the nurse's cold hands, the nurse wears them primarily to maintain standard precautions, which is required by the Occupational Safety and Health Administration.

A client with diabetes gives birth to a 9-lb, 10-oz neonate at 38 weeks. Which serum level of the neonate should be assessed immediately after birth? 1. Potassium 2. Sodium 3. Bilirubin 4. Glucose

4. Glucose Glucose monitoring of the infant born to a mother with diabetes is essential because he is at risk for developing hypoglycemia after birth. It isn't necessary to immediately monitor potassium, sodium or bilirubin levels.

When assessing a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). Which condition makes this client more susceptible to such infections? 1. Electrolyte imbalances 2. Decreased insulin needs 3. Hypoglycemia 4. Glycosuria

4. Glycosuria Glycosuria predisposes the pregnant diabetic client to vaginal infections (especially Candida vaginitis) and UTIs, because the hormonal changes of pregnancy affect vaginal pH and the bladder. Electrolyte imbalances and hypoglycemia aren't associated with vaginal infections or UTIs. Insulin requirements may decrease in early pregnancy; however, as the client's food intake improves and maternal and fetal glycogen stores increase, insulin requirements also rise.

Which of the following would be least likely to affect the parent-child relationship? 1. Readiness for the pregnancy 2. Nature of the pregnancy 3. Maturity of the parents 4. Grandparent support

4. Grandparent support Extended family is important to the social development of the infant but doesn't affect the parent-child relationship. Readiness for pregnancy, a healthy and uncomplicated pregnancy, and parental maturity are factors that promote a positive parent-child relationship.

A postpartum nurse is taking the vital signs of a client who delivered a healthy infant 4 hours ago. The nurse notes that the client's temperature is 100.2 ° F. Which of the following actions would be appropriate? 1. Notify the physician. 2. Document the findings. 3. Retake the temperature in 15 minutes. 4. Increase hydration by encouraging oral fluids.

4. Increase hydration by encouraging oral fluids. The client's temperature should be taken every 4 hours while she is awake . Temperatures up to 100.4 ° F (38 ° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Contacting the physician is not necessary. Taking the temperature in another 15 minutes is an unnecessary action.

The charge nurse informs a staff nurse of a new admission in active labor who is coming to the labor and delivery unit. The nurse is currently caring for a client in labor and another client who has a cesarean section scheduled within the next half hour. How can the nurse best manage her client care assignment? 1. Call the obstetrician and ask him to postpone the cesarean section. 2. Refuse to accept the new admission. 3. Ask the administrative assistant to complete the new client's paperwork. 4. Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients.

4. Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients. A nurse in the labor and delivery unit can't safely care for three clients. Therefore, the nurse should notify the charge nurse that an additional staff member is needed to safely meet the needs of the increasing client census. Postponing the cesarean section isn't the best option. The nurse should ask the administrative assistant to assist with paperwork; however, an additional nurse is also needed. The nurse can't refuse to admit a client in labor.

A pregnant client reports to a health care clinic , complaining of loss of appetite, weight loss, and fatigue. After assessment of the client , tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. The nurse provides instructions to the client regarding therapeutic management of the tuberculosis and the nurse tells the client that: 1. Therapeutic abortion is required. 2. She will have to stay at home until treatment is completed. 3. Medication will not be started until after delivery of the fetus. 4. Isoniazid (INH) plus rifampin (Rifadin) will be required for 9 months.

4. Isoniazid (INH) plus rifampin (Rifadin) will be required for 9 months. More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid (INH) plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with INH to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.

A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention? 1. Urine specific gravity 1.010 2. Serum potassium 4 mEq/L 3. Serum sodium 140 mEq/L 4. Ketones in urine

4. Ketones in urine Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. The other laboratory values listed are all within normal limits.

The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following? 1. Poor clotting mechanism 2. High hemoglobin (Hb) levels between 14 and 20 g/100 ml of blood 3. Persistent fetal circulation 4. Large, immature liver

4. Large, immature liver The primary cause of neonatal jaundice is the immaturity of the liver and its inability to break down red cells effectively. Poor clotting mechanisms, elevated Hb, and persistent fetal circulation contribute to the jaundice but aren't causes of it.

When questioned, a pregnant client admits she sometimes has several glasses of wine with dinner. Her alcohol consumption puts her fetus at risk for which condition? 1. Alcohol addiction 2. Anencephaly 3. Down syndrome 4. Learning disability

4. Learning disability Maternal alcohol use during pregnancy may cause fetal and neonatal central nervous system deficits such as learning disabilities. It also may lead to characteristic physical anomalies and growth retardation. Maternal alcohol use doesn't cause alcohol addiction in the fetus or neonate. Anencephaly occurs when the cranial end of the neural tube fails to fuse before the 26th day of gestation; this condition isn't related to maternal alcohol use. Down syndrome results from a chromosomal disorder.

A client in the first stage of labor is being monitored using an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Into what position should the nurse assist the client? 1. Supine 2. Right lateral 3. Prone 4. Left lateral

4. Left lateral Variable decelerations are transient drops in the fetal heart rate that can occur before, during, or after a contraction. The left lateral position (not the right lateral position) is the ideal position for any pregnant client, as it prevents maternal hypotension caused by inferior vena cava compression, which reduces placental perfusion. Supine positioning may cause inferior vena cava compression. Pregnant individuals can't safely assume the prone position.

The nurse is assessing a client who has been admitted to the labor and delivery area. Which technique does the nurse use to determine fetal position and presentation? 1. Abdominal ultrasonography 2. Fetal heart tone auscultation 3. Palpation of contractions 4. Leopold's maneuvers

4. Leopold's maneuvers Leopold's maneuvers, a series of abdominal palpations, are used to determine fetal position, presentation, and lie. Abdominal ultrasonography is used throughout pregnancy to determine the positions of the uterus and cervix, detect an abnormal fetus, determine the number of fetuses, take fetal measurements, and estimate gestational age. Fetal heart tone auscultation is done to assess the fetal heart rate. Palpation of contractions helps to distinguish true labor contractions from Braxton Hicks contractions.

While caring for pregnant adolescents, the nurse should develop a care plan that incorporates which health concern? 1. Age of menarche 2. Family and home life 3. Healthy eating habits 4. Level of emotional maturity

4. Level of emotional maturity When assessing an adolescent initially, the nurse should try to determine the client's level of emotional maturity. This forms the basis for the nursing care plan. Age of menarche, family and home life, and healthy eating habits, though important, aren't as significant as determining the emotional maturity of the client.

In a small rural facility, the nurse is caring for a neonate born to a diabetic mother. The neonate's respiratory rate is 70 breaths/minute, heart rate 162 beats/minute, and oxygen saturation is 92% on room air. The nurse obtains a blood glucose level, which is 50 mg/dl. Realizing the seriousness of the neonate's condition, the pediatrician arranges transfer to a level III nursery. The social worker asks the nurse what transportation arrangements are needed. How should the nurse respond? 1. Ambulance with advanced life support capabilities 2. Ambulance with transport team from the level III facility 3. Ambulance from the rural hospital manned with emergency medical technicians 4. Medical helicopter from the level III facility

4. Medical helicopter from the level III facility The neonate is critically ill and requires immediate transport to the level III facility. The quickest way to achieve this transfer is by the medical helicopter sent from the level III facility. The facility helicopter is staffed by health care providers who specialize in caring for critically ill neonates; therefore, care can begin as soon as the team arrives. Options 1, 2, and 3 don't provide safe, effective means of transportation for this critically ill neonate.

314. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.

4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches. Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration , or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment , the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

A nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern.

4. Monitor the newborn's response to feedings and weight gain pattern. Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after delivery. These newborns may exhibit hyperirritability, vomiting , diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are inappropriate interventions..

After administering bethanechol (Duvoid) to a client with urine retention, the nurse monitors the client for adverse effects. Which is most likely to occur? 1. Decreased peristalsis 2. Increased heart rate 3. Dry mucous membranes 4. Nausea and vomiting

4. Nausea and vomiting Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may greatly increase.

Which point should the nurse include when teaching mothers about preventing childhood falls? 1. Place the infant in a car seat in the rear facing position until he is age 1 year or weighs 20 lb. 2. Place the infant in an infant rocker when he's awake. 3. Use small pillows in the crib to prevent the infant from rolling onto the stomach. 4. Never leave the infant alone on an elevated surface.

4. Never leave the infant alone on an elevated surface. The nurse should instruct mothers not to leave their infant unattended on an elevated surface because the infant may fall. The current recommendation for car-seat safety is to place the infant in a rear-facing position until he is age 1 year and weighs 20 lb. Leaving an infant in a rocker whenever he is awake is neglectful; an infant needs interaction and physical contact with others. Although safety experts recommend that infants sleep on their back, pillows shouldn't be placed in the crib because they pose a smothering hazard to an infant of any age.

A primigravid client is admitted to the labor and delivery area. Assessment reveals fetal malpresentation, yellow amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What should the nurse do? 1. Increase the I.V. oxytocin flow rate, as ordered, to hasten labor and delivery. 2. Reassess the client for continued normal findings in 15 minutes. 3. Help the client into the lithotomy position for delivery. 4. Notify the physician and surgical team of an emergency.

4. Notify the physician and surgical team of an emergency Because the abnormal FHR and amniotic fluid color suggest fetal distress, the nurse should notify the physician and surgical team. The other options describe actions that wouldn't address this emergency situation.

The nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning? 1. On the day of discharge 2. When the client expresses readiness to learn 3. When the client's vomiting has stopped 4. On admission to the facility

4. On admission to the facility Discharge planning should begin when a client is first admitted to the facility. Initially, discharge planning requires collecting information about the client's home environment, support systems, functional abilities, and finances. This information is used to determine what support services will be needed. Notifying support services on the day of discharge won't be sufficient to ensure meeting the client's needs in a timely fashion. Waiting until the day of discharge to begin planning is also likely to cause the client to become overwhelmed and anxious. Such factors as when the client stops vomiting and expresses readiness to learn shouldn't influence when the nurse begins discharge planning.

A client is at the end of her 1st postpartum day. When assessing her uterus, the nurse expects to find the top of the fundus at the midline and at which position? 1. At the level of the umbilicus 2. Below the level of the symphysis pubis 3. One fingerbreadth above the umbilicus 4. One fingerbreadth below the umbilicus

4. One fingerbreadth below the umbilicus Fundal height decreases about one fingerbreadth each postpartum day. The fundus reaches the level of the umbilicus 6 to 12 hours after birth. It descends below the level of the symphysis pubis by the 10th day after delivery. The fundus rarely is palpated above the umbilicus.

A nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. The nurse explains to the mother that this is routinely done to: 1. Protect the newborns eyes from possible infections acquired while hospitalized. 2. Prevent cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimize the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevent ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.

4. Prevent ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection. Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for administering this medication to a newborn infant.

At 39 weeks' gestation, a pregnant client is admitted to the labor and delivery area in active labor. During the admission interview, she reports that her membranes haven't ruptured. Her history reveals that this is her third pregnancy, she previously experienced a stillbirth at 38 weeks' gestation, and she has one child at home. Which of these findings indicates the need for electronic fetal monitoring (EFM)? 1. Third pregnancy 2. Intact membranes 3. 39 weeks' gestation 4. Previous stillbirth

4. Previous stillbirth Previous stillbirth is one of several maternal factors that indicate the need for EFM. Other indications for EFM include certain fetal factors, such as meconium staining; certain pregnancy factors, such as amnionitis; and certain uterine factors, such as regional anesthesia. A third pregnancy, intact membranes, and 39 weeks' gestation don't place the client at risk for problems that require close fetal monitoring.

Which function would the nurse expect to be unrelated to the placenta? 1. Production of estrogen and progesterone 2. Detoxification of some drugs and chemicals 3. Exchange site for food, gases, and waste 4. Production of maternal antibodies

4. Production of maternal antibodies Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.

A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to do which of the following? 1. Slow contractions 2. Enhance fetal growth 3. Prevent infection 4. Promote fetal lung maturity

4. Promote fetal lung maturity Betamethasone is given to promote fetal lung maturity by enhancing the production of surface-active lipoproteins. It has no effect on contractions, fetal growth, or infection.

To ensure that the breast-feeding neonate's weight loss remains within the expected parameter of 5% to 10%, the nurse should initially establish which of the following types of feeding schedules? 1. Maintain the neonate on an every-2-hours feeding schedule. 2. Put the neonate to the mother's breast at least every 4 hours. 3. Use supplementary bottles until the mother's milk comes in. 4. Provide feeding on demand.

4. Provide feeding on demand. Breast-feeding schedules should respond to the demands of the neonate, at a minimum of every 4 hours. A neonate may not be hungry or willing to eat every 2 hours. Every 4 hours may be too long for the neonate. Using supplementary bottles may interfere with the mother's milk production and cause nipple confusion.

As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy? 1. Decreased appetite 2. Inadequate fluid intake 3. Prolonged gastric emptying 4. Reduced intestinal motility

4. Reduced intestinal motility During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.

A client is diagnosed with oligohydramnios during a clinic visit. Before the client delivers, the nurse should notify the nurses working in the nursery about the diagnosis so they are aware of which complication that's commonly associated with oligohydramnios? 1. Hypospadias 2. Talipes equinovarus 3. Presence of the Babinski reflex 4. Renal malformations

4. Renal malformations Oligohydramnios is commonly associated with renal malformations in the neonate. These malformations include renal aplasia, dysplastic kidneys, and obstructive lesions of the lower urinary tract. Hypospadias, an abnormal congenital opening of the male urethra on the underside of the penis, isn't associated with oligohydramnios. Talipes equinovarus, commonly known as clubfoot, isn't associated with oligohydramnios. The Babinski reflex, dorsiflexion of the great toe when the sole of the foot is stimulated, is a normal reflex in neonates.

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. Who should the nurse manager consult to help the staff cope with this unexpected death? 1. The human resource director, so she can arrange vacation time for the staff 2. The physician, so he can provide education about HELLP syndrome 3. The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff 4. The chaplain, because his educational background includes strategies for handling grief

4. The chaplain, because his educational background includes strategies for handling grief The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.

The nurse is reviewing the history of a postpartum client. Which history factor most strongly suggests that this client will experience afterpains? 1. The client delivered at 39 weeks' gestation. 2. The client smokes cigarettes. 3. The client has decided to bottle-feed her neonate. 4. The client is a gravida 6, para 5.

4. The client is a gravida 6, para 5. In a multiparous client, decreased uterine muscle tone leads to alternating relaxation and contraction during uterine involution; this, in turn, causes afterpains. A gestation of 39 weeks and a history of cigarette smoking don't contribute directly to afterpains. A breast-feeding (not bottle-feeding) client may experience afterpains from oxytocin release, which stimulates the uterus to contract and thus enhances involution. However, the decision to bottle-feed doesn't cause afterpains.

During a nonstress test (NST), the nurse notes three fetal heart rate (FHR) increases of 20 beats/minute, each lasting 20 seconds. These increases occur only with fetal movement. What does this finding suggest? 1. The client should undergo an oxytocin challenge test. 2. The test is inconclusive and must be repeated. 3. The fetus is nonreactive and hypoxic. 4. The fetus isn't in distress at this time.

4. The fetus isn't in distress at this time. In an NST, reactive (favorable) results include two to three FHR increases of 15 beats/minute or more, each lasting 15 seconds or more and occurring with fetal movement. An oxytocin challenge test is performed to stimulate uterine contractions and evaluate the FHR. If results are inconclusive, a nipple stimulation contraction test may be ordered. A nonreactive result occurs when the FHR doesn't rise 15 beats/minute or more over the specified time; a nonreactive result may indicate fetal hypoxia.

A nurse evaluates the ability of a hepatitis B- positive mother to provide safe bottle-feeding to her infant during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the infant? 1. The mother requests that the window be closed before feeding. 2. The mother holds the infant properly during feeding and burping. 3. The mother tests the temperature of the formula before initiating feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals , and to reduce maternal complications. Option 4 provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.

Which of the following would be least likely to indicate anticipated bonding behaviors by new parents? 1. The parents' willingness to touch and hold the newborn 2. The parents' expression of interest about the size of the newborn 3. The parents' indication that they want to see the newborn 4. The parents' interactions with each other

4. The parents' interactions with each other Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. Willingness to touch and hold the neonate, expressing interest about the neonate's size, and indicating a desire to see the neonate are behaviors indicating parental bonding.

A physician has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks a nurse about the procedure. The nurse tells the client that: 1. The procedure takes about 2 hours. 2. It will be necessary to drink 1 to 2 quarts of water before the examination. 3. Gel is spread over the abdomen, and a round disk transducer will be moved over the abdomen to obtain the picture. 4. The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel.

4. The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel. Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in a lithotomy position and a transvaginal probe , encased in a disposable cover and coated with a gel that provides lubrication and promotes conductivity, is inserted into the vagina. The client may feel more comfortable if she is allowed to insert the probe. The procedure takes about 10 to 15 minutes. Options 2 and 3 identify components of abdominal ultrasound.

Which of the following statements summarizes the underlying principle for the development of a parent-child relationship? 1. The parents-to-be had good role models in their childhood. 2. The relationship is part of the adult maturational process. 3. The development is directly related to the physical needs of the newborn. 4. The relationship is based on the need for early and frequent parent-infant contact.

4. The relationship is based on the need for early and frequent parent-infant contact. Early and frequent contact promotes love and satisfaction and can support the learned parental behavior that enhances parenting abilities and reduces ambivalence and feelings of resentment. Having good role models in childhood may be helpful but isn't the primary principle. Part of the adult maturational process excludes adolescents, who can form strong infant attachments. The relationship isn't directly related to the neonate's physical needs because human contact is needed for the infant to survive.

As part of the postpartum follow-up, the nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information, which of the following assessments would the nurse make? 1. The client's behavior represents signs of postpartum depression. 2. The client is acting abnormally and her physician needs to be notified. 3. A home assessment is necessary to assure the well-being of the mother and the baby. 4. This is expected behavior for a client 3 to 7 days postpartum.

4. This is expected behavior for a client 3 to 7 days postpartum. Normal processes during postpartum include the withdrawal of progesterone and estrogen and lead to the psychological response known as "the blues." Postpartum depression is a psychiatric problem that occurs later in postpartum and is characterized by more severe symptoms of inadequacy. Because the client's behavior is normal, notifying her physician and conducting a home assessment aren't necessary.

The nurse is teaching a postpartum client how to perform Kegel exercises. What is the primary purpose of these exercises? 1. To prevent urine retention 2. To relieve lower back pain 3. To strengthen the abdominal muscles 4. To strengthen the perineal muscles

4. To strengthen the perineal muscles Kegel exercises strengthen and increase elasticity of the pubococcygeal muscle. Urine retention may occur if the client stops the urine stream when performing Kegel exercises. The nurse should recommend other types of exercises to relieve lower back pain and strengthen the abdominal muscles.

When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor? 1. Active phase 2. Latent phase 3. Descent phase 4. Transitional phase

4. Transitional phase In the transitional phase, the cervix dilates from 8 to 10 cm, and intense contractions occur every 1½ to 2 minutes and last for 45 to 90 seconds. In the active phase, the cervix dilates from 5 to 7 cm, and moderate contractions progress to strong contractions that last 60 seconds. In the latent phase, the cervix dilates 3 to 4 cm, and contractions are short, irregular, and mild. No descent phase exists. (Fetal descent may begin several weeks before labor but usually doesn't occur until the second stage of labor.)

A 32-year-old multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. What phase of labor is she in? 1. Active phase 2. Latent phase 3. Expulsive phase 4. Transitional phase

4. Transitional phase The transitional phase of labor extends from 8 to 10 cm; it's the shortest but most difficult and intense for the client. The latent phase extends from 0 to 3 cm; it's mild in nature. The active phase extends from 4 to 7 cm; it's moderate for the client. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

The nurse is caring for a client who's in the first stage of labor. What is the shortest but most difficult part of this stage? 1. Active phase 2. Complete phase 3. Latent phase 4. Transitional phase

4. Transitional phase The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4½ to 6 hours; it's characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

During a prenatal visit at 20 weeks' gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks' gestation, which procedure is used to detect fetal anomalies? 1. Amniocentesis 2. Chorionic villi sampling 3. Fetoscopy 4. Ultrasound

4. Ultrasound Ultrasound is used between 18 and 40 weeks' gestation to identify normal fetal growth and detect fetal anomalies and other problems. Amniocentesis is done during the third trimester to determine fetal lung maturity. Chorionic villi sampling is performed at 8 to 12 weeks' gestation to detect genetic disease. Fetoscopy is done at approximately 18 weeks' gestation to observe the fetus directly and obtain a skin or blood sample.

A client is in the third stage of labor. Which finding indicates impending placental separation? 1. Increased maternal anxiety 2. Severe rectal pressure 3. Increased bloody show 4. Umbilical cord lengthening

4. Umbilical cord lengthening Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the vagina, and a change in uterine shape from disklike to globular. Increased maternal anxiety occurs during the transitional phase of the first stage of labor. Severe rectal pressure and increased bloody show are common during the second stage.

A client is 9 days postpartum and breast-feeding her baby. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? 1. Wear a loose-fitting bra to avoid constricting the milk ducts. 2. Stop breast-feeding permanently. 3. Take antibiotics until the pain is relieved. 4. Use a warm moist compress over the painful area.

4. Use a warm moist compress over the painful area. Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding may resume once the infection is treated. The client will need to pump the breast in the meantime to keep the breast empty of milk and to ensure an adequate milk supply. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.

A client tells the nurse that she suspects her amniotic membranes broke 2 hours ago. Because the goal of care for this client is to prevent infection (chorioamnionitis), the care plan should include: 1. assessing the fetal heart rate once every hour. 2. limiting vaginal examinations to once every hour. 3. assessing vital signs, especially temperature, every 4 hours. 4. confirming membrane rupture by using a sterile speculum and cotton-tipped applicator to assess fluid.

4. confirming membrane rupture by using a sterile speculum and cotton-tipped applicator to assess fluid. To prevent infection, the nurse must use sterile technique to assess amniotic fluid and thus confirm membrane rupture. The nurse should assess the fetal heart rate every 30 minutes because fetal tachycardia signals chorioamnionitis. Vaginal examinations introduce bacteria into the vagina and should be performed only when necessary — for example, before opioid administration and to assess suspected cord prolapse. The nurse should assess vital signs, especially temperature and pulse, every 2 hours to detect early signs of infection.

The nurse is reviewing a pregnant client's nutritional status. To determine whether she has an adequate intake of vitamin A, the nurse should assess her diet for consumption of: 1. fish. 2. cereals. 3. meat. 4. dairy products.

4. dairy products. Common food sources of vitamin A include dairy products, liver, egg yolks, fruits, and vegetables. Fish and meat are good sources of protein. Cereals, especially whole grains, are good sources of niacin, vitamin B1, and vitamin B6.

The nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The nurse knows that the goal of phototherapy is to: 1. prevent hypothermia. 2. promote respiratory stability. 3. decrease the serum conjugated bilirubin level. 4. decrease the serum unconjugated bilirubin level.

4. decrease the serum unconjugated bilirubin level. The goal of phototherapy is to decrease the serum unconjugated bilirubin level because a high level may lead to bilirubin encephalopathy (kernicterus). Phototherapy doesn't prevent hypothermia or promote respiratory stability. It has no effect on conjugated bilirubin, a water-soluble substance easily excreted in urine and stool.

A client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves: 1. chemical barriers that act as spermicidal agents. 2. hormones that prevent ovulation. 3. mechanical barriers that prevent sperm from reaching the cervix. 4. determination of the fertile period to identify safe times for sexual intercourse.

4. determination of the fertile period to identify safe times for sexual intercourse. The symptothermal method of family planning combines basal body temperature measurement with analysis of cervical mucus changes to determine the fertile period more accurately and thus identify safe and unsafe periods for sexual intercourse. A natural family planning method, it doesn't involve use of chemical barriers, hormones, or mechanical barriers.

The nurse is teaching a client about oral contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct her to: 1. take all the missed doses as soon as she discovers the oversight. 2. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle. 3. take three pills for the next 3 days and use an alternative contraceptive method until the next cycle. 4. discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule.

4. discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. A client who misses three or more pills in a row should discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. The other options listed don't assure effectiveness and also increase the risk of adverse reactions.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to: 1. eat three well-balanced meals per day. 2. exercise 1 hour before each meal. 3. take a vitamin and mineral supplement. 4. divide daily food intake into five or six meals.

4. divide daily food intake into five or six meals. To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue.

When teaching a group of pregnant teens about reproduction and conception, the nurse is correct when stating that fertilization occurs: 1. in the uterus. 2. when the ovum is released. 3. near the fimbriated end. 4. in the first third of the fallopian tube.

4. in the first third of the fallopian tube. Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.

The nurse is providing dietary teaching to a pregnant client. To help meet the client's iron needs, the nurse should advise her to eat: 1. grains and milk. 2. tomatoes and fish. 3. eggs and citrus fruit. 4. spinach and beef.

4. spinach and beef. Common food sources of iron include spinach, beef, liver, prunes, pork, broccoli, legumes, and whole wheat breads and cereals. Grains are good sources of carbohydrates; milk is high in vitamin D; and fish, eggs, and milk are high in protein. Tomatoes and citrus fruits are high in vitamins A and C.

Nitrazine test

A nitrazine test strip is used to detect the presence of amniotic fluid in vaginal secretions. Vaginal secretions have a pH of 4.5 to 5.5 and do not affect the nitrazine strip or swab. Amniotic fluid has a pH of 7.0 to 7.5 and turns the nitrazine strip or swab blue.

Hypertonic uterine activity

Assessment of uterine activity includes frequency, duration, intensity of contractions, and uterine resting tone. The uterus should relax between contractions for 60 seconds or longer. Uterine contraction intensity is about 50 to 75 mm Hg during labor and may reach 110 mm Hg with pushing during the second stage. The average resting tone is 5 to 15 mm Hg. In hypertonic uterine activity, the uterine resting tone between contractions is high, reducing uterine blood flow and decreasing fetal oxygen supply.

Predisposing Conditions for Disseminated Intravascular Coagulation

Abruptio placentae Amniotic fluid embolism Gestational hypertension Intrauterine fetal death Liver disease Sepsis

Fetal attitude

Attitude is the relationship of the fetal body parts to one another. Normal intrauterine attitude is flexion, in which the fetal back is rounded, the head is forward on the chest, and the arms and legs are folded in against the body. The other attitude, extension, tends to present larger fetal diameters.

Breast Care for Non- Breast-Feeding Mothers

Avoid nipple stimulation. Apply a breast binder, wear a snug-fitting bra, apply ice packs, or take a mild analgesic. Engorgement usually resolves within 24 to 36 hours after it begins.

Accelerations

Brief, temporary increases in FHR of at least 15 beats more than baseline and lasting at least 15 seconds Usually are a reassuring sign, reflecting a responsive, nonacidotic fetus Usually occur with fetal movement d. May be nonperiodic (having no relation to contractions) or periodic May occur with uterine contractions, vaginal examinations, or mild cord compression, or when the fetus is in a breech presentation.

Breast tenderness in pregnancy (when/cause)

Can occur in the first through the third trimesters Caused by increased levels of estrogen and progesterone

How does pregnancy effect vital signs?

During pregnancy, a woman's pulse rate may increase about 10 to 15 beats/ min, the blood pressure slightly decreases in the second trimester, and the respiratory rate remains unchanged or slightly increases.

Maternal insulin needs during the first trimester

During the first trimester, maternal insulin needs decrease.

Early decelerations

Early decelerations are decreases in FHR below baseline; the rate at the lowest point of the deceleration usually remains greater than 100 beats/ min. Early decelerations occur during contractions as the fetal head is pressed against the mother's pelvis or soft tissues, such as the cervix, and return to baseline FHR by the end of the contraction. Tracing shows a uniform shape and mirror image of uterine contractions. Early decelerations are not associated with fetal compromise and require no intervention.

Fetal presentation

Portion of the fetus that enters the pelvic inlet first Cephalic: Head first - the most common presentation. 4 variations— vertex, military, brow, and face. Breech: Buttocks present first. Delivery by cesarean section may be required, although vaginal birth is often possible. 3 variations— frank, full (complete), and footling Shoulder - Fetus is in a transverse lie, or the arm, back, abdomen, or side could present. If the fetus does not spontaneously rotate, or if it is impossible to turn the fetus manually, a cesarean section may need to be performed.

Spontaneous abortion

Pregnancy ends because of natural causes

Preeclampsia

Pregnancy-specific syndrome that usually occurs after 20 weeks of gestation and is determined by gestational hypertension plus proteinuria

lecithin-to-sphingomyelin (L/ S) ratio

Ratio of two components of amniotic fluid, used for predicting fetal lung maturity; normal L/ S ratio in amniotic fluid is 2: 1 or greater when the fetal lungs are mature.

Interventions for labor stage 3

a. Assess maternal vital signs. b. Assess uterine status. c. Provide parents with an explanation regarding expulsion of the placenta. d. After expulsion of the placenta, uterine fundus remains firm and is located 2 fingerbreadths below the umbilicus. e. Examine placenta for cotyledons and membranes to verify that it is intact. f. Assess mother for shivering and provide warmth. g. Promote parental-neonatal attachment.

Breast changes during pregnancy

a. Breast size increases, and breasts may be tender. b. Nipples become more pronounced. c. The areolae become darker in color. d. Superficial veins become prominent. e. Hypertrophy of Montgomery's follicles occurs. f. Colostrum may leak from the breast.

Interventions for urinary urgency and frequency in pregnancy

a. Drinking adequate amounts of fluid during the day b. Limiting fluid intake in the evening c. Voiding at regular intervals d. Sleeping side-lying at night e. Wearing perineal pads, if necessary f. Performing Kegel exercises.

Interventions for nausea and vomiting in pregnancy

a. Eating dry crackers before arising b. Avoiding brushing teeth immediately after arising c. Eating small, frequent, low-fat meals during the day d. Drinking liquids between meals rather than at meals e. Avoiding fried foods and spicy foods f. Asking the physician or nurse-midwife about acupressure (some types may require a prescription) g. Asking the physician or nurse-midwife about the use of herbal remedies

Interventions for constipation in pregnancy

a. Eating high-fiber foods b. Drinking sufficient fluids c. Exercising regularly d. Consulting with the physician or nurse -midwife about interventions such as the use of stool softeners, laxatives, or enemas

Interventions for heartburn in pregnancy

a. Eating small, frequent meals b. Sitting upright for 30 minutes after a meal c. Drinking milk between meals d. Avoiding fatty and spicy foods e. Performing tailor-sitting exercises f. Consulting with the physician or nurse-midwife about the use of antacids

Interventions for ankle edema in pregnancy

a. Elevating the legs at least twice a day and when resting b. Sleeping in a side-lying position c. Wearing supportive stockings or support hose d. Avoiding sitting or standing in one position for long periods

Interventions for nasal stuffiness in pregnancy

a. Encouraging the use of a humidifier b. Avoiding the use of nasal sprays or antihistamines (the physician or nurse-midwife should be consulted about their use)

Interventions for HIV+ patients during labor

a. If the fetus has not been exposed to HIV in utero, the highest risk exists during delivery through the birth canal. b. Avoid the use of internal scalp electrodes for monitoring of the fetus. c. Avoid episiotomy to decrease the amount of maternal blood in and around the birth canal. d. Avoid the administration of oxytocin (Pitocin ) because contractions induced by oxytocin can be strong, causing vaginal tears or necessitating an episiotomy. e. Place heavy absorbent pads under the mother's hips to absorb amniotic fluid and maternal blood. f. Minimize the neonate's exposure to maternal blood and body fluids; promptly remove the neonate from the mother's blood after delivery. g. Suction fluids from the neonate promptly. h. Prepare to administer zidovudine as prescribed to the mother during labor and delivery.

Interventions for stage 2 of labor

a. Perform assessments every 5 minutes. b. Monitor maternal vital signs. c. Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor. d. Assess FHR before, during , and after a contraction, noting that normal FHR is 120 to 160 beats/ min. e. Monitor uterine contractions by palpation or tocodynamometer, determining frequency, duration, and intensity. f. Provide mother with encouragement and praise and provide for rest between contractions. g. Keep mother and partner informed of progress. h. Maintain privacy. i. Provide ice chips and ointment for dry lips. j. Assist mother into a position that promotes comfort and facilitates pushing efforts, such as lithotomy, semisitting, kneeling, side-lying, or squatting. k. Monitor for signs of approaching birth, such as perineal bulging or visualization of the fetal head. l. Prepare for birth (expulsion of the fetus).

Interventions for labor stage 4

a. Perform maternal assessments every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 2 hours (or as per agency policy). b. Provide warm blankets. c. Apply ice packs to the perineum. d. Massage the uterus if needed, and teach the mother to massage the uterus. e. Provide breast-feeding support as needed.