OB test 3 study guide

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

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

The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?

Experience of additional back pain

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

a moderate amount of lochia rubra rationale: The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe if the infant is in the supine position?

abdomen

is defined as abnormal or difficult labor

dystocia

a prophylactic agent is instilled in both eyes of all newborns to prevent which condition?

gonorrhea and chlamydia

which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head?

head circumference 32 cm, chest 34 cm head should be 2 cm greater than chest

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

ineffective airway clearance r/t mucus and secretions

After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have:

intense back pain

_______ reflex is also called the embrace reflex

moro

Which of the following concepts would the nurse incorporate into the plan of care when assessing pain in a newborn with special needs? Newborns experience pain primarily with surgical procedures. Preterm newborns in the NICU are at the least risk for pain. Pain assessment needs to be comprehensive and frequent. A newborn's facial expression is the primary indicator of pain.

pain assessment

after spontaneous abortion a woman who is RH-negative needs to receive______

rhogam

letdown reflex

triggered by thoughts of baby, baby crying, sexual orgasm, can be suppressed by fear, pain, embarrassment,

a slight temperature elevation is normal during the first 24 hours after delivery

true

acrocyanosis is normal and occurs intermittently in a newborn

true

____ id the cheesy substance that protects the fetal skin in utero

vernix caseosa

is it normal to see a small amount of blood tinged material on the diaper of a baby girl

yes and this is due to the withdrawal of maternal hormones and is referred to as pseudomenstruation

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group?

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

pt should void within how many hours after giving birth

6-8

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

A full bladder or rectum can impede fetal descent.

Methergine has been ordered for a postpartum woman because of excessive bleeding. The nurse should question this order if which of the following is present?

BP of 158/96

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply.

ID bands, warmer bed, suction equipment,

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

SIDS

The nurse is providing care to several newborns with variations in gestational age and birth weight. When developing the plan of care for these newborns, the nurse focuses on energy conservation to promote growth and development. Which measures would the nurse include in the nursing plans of care? Select all that apply. a. Keeping the handling of the newborn to a minimum b. Maintaining a neutral thermal environment c. Decreasing environmental stimuli d. Initiating early oral feedings e. Using thermal warmers in all cribs f. Promoting kangaroo care by caretakers

a, b, c

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

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

Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic change influences breast engorgement?

an increase in blood and lymph supply to the breast

the development of strong affectional ties between an infant and significant other defines the process of

attachment

In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman's behavior to be characterized as which of the following?

being passive and dependent

when caring for a newborn having phototherapy the nurse needs to monitor ___ levels

bilirubin

women who have c sections are at higher risk for the following physical problems

bleeding, infection, pain,mortality and morbidity

_____ refers to the enduring nature of the attachment relationship

bonding

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

calories and protein

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

check the lochia rationale: The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion.

Which of the following findings would lead the nurse to suspect that a woman is developing a postpartum complication?

chest pain experienced when ambulating

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status

lochia rubra

day 1-3

what are temps less than 100.4 attributed to

dehydration and the pt should be encouraged to drink more fluids

the most common cause of postpartum hemorrhage is retained placental fragments

false

which one of the following immunizations is most commonly received by newborns before hospital discharge

hep B

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?

inspecting posture, color and respiratory effort rationale: The nurse begins by assessing the neonate's posture, color, and respiratory effort. These three parameters provide a general overview of the infant's condition and adaptation to extrauterine life. Skin condition and birthmarks as well as head and chest circumference are part of the comprehensive physical and are documented within the first day of life. Bowel sounds are not present until about 15 minutes after birth and the infant may not void until 24 hours of age.

vitamin k is administered to a newborn:

intramuscularly

the excess number of RBCs that are present in the neonate can lead to ______

jaundice

_____ exercises help to strengthen the pelivic floor muscles

kegel

Which of the following factors in a postpartum woman's history would lead the nurse to monitor the woman closely for an infection?

manually extracted placenta

_____ is the thick tarry sticky dark green stool passed within the first 48 hours after birth

mecomium

is the thick, tarry, sticky, dark green stool passed within the first 48 hours after birth

meconium

the _____ reflex is also called the startle reflex

moro

the ____ period is defined as the first 28 days of life

neonatal

which of the following findings in a newborn would be considered normal?

passage of meconium within the first 24 hours

the abdomen of a newborn typically appears ________ w/o appearing distended

protuberant

what is the best incision used for c section

the low transverse is the most common and best incision

define uterine involution

the return of the uterus to the pre-pregnant state

A pregnant client at 28 weeks' gestation in preterm labor has received a dose of betamethasone IM today at 1400. The client is scheduled to receive a second dose. At which time would the nurse expect to administer that dose?

tomorrow at 1400 rationale: Betamethasone is given as two intramuscular injections, given 24 hours apart. Because the woman got her first dose at 1400 today, then her second dose would be given at 1400 tomorrow.

postpartum wound infections are usually not identified until the women has been discharged from the hospital

true

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

wearing a tight-fitting supportive bra

does the postpartum woman commonly exhibit bradycardia

yes

is profuse diaphoresis common during the early postpartum period

yes

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

you should be seen by your healthcare provider if you have blurred vision The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

what is assessed at time of birth with the umbilical cord

2 arteries and 1 vein should be present. if not further diagnostic test will be done to assess for other abnormalities

a mother choosing to breast feed requires an additional _____ calories per day over her diet during pregnancy

200

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

500 ml rationale: Postpartum hemorrhage is defined as a cumulative blood loss greater than 500 mL after a vaginal birth and greater than 1,000 mL after a cesarean birth, with signs and symptoms of hypovolemia within 24 hours of the birth process.

A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client?

Complete the full course of antibiotic prescribed, even if you begins to feel better. rationale: Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis and administering antibiotics for a full 10 to 14 days. The woman should empty her breasts every 1.5 to 2 hours to help prevent milk stasis and the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?

Evaporative rationale: Evaporative heat loss occurs with the evaporation of fluid from the infant.

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

ID the newborn The nurse will identify the correct newborn before administering phytonadione (vitamin K).

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

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

what could elevations in B/P indicate even after delivery

PIH

a pt experiences a third degree laceration during delivery. the initial interventions the nurse should provide include ___,________, and later ____.

an ice pack, topical medications such as dermoplast and epifoam and later sitz baths

what is done jfor women who test positive for group b strep vaginally

antibiotics are given

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?

apply ice rationale: Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. warm compresses will promote blood flow and hence, milk production.

Which of the following would the nurse expect to include in the plan of care for a woman with mastitis who is receiving antibiotic therapy?

apply warm or cold compresses and administer analgesics

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus. rationale: This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions such as: inspect the perineum for lacerations, increase IV flow, call the provider, are to be done after the initial fundal massage.

a postpartum mother appears very pale and states she is bleeding heavily. The nurse should first:

assess the fundus and ask her about her voiding status

BUBBLEE

breast, uterus, bladder, bowel, lochia, episiotomy/laceration/c-section incision, emotional

A preterm infant is placed under the radiant heat warmer after birth. The nurse evaluates the temperature frequently to prevent which of the following: Cold stress Respiratory depression Tachycardia Thermogenesis

cold stress

a newborn experiencing heat loss can develop

cold stress

refers to the enduring nature of the attachment relationship

commitment

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

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

A new mother was brought to the postpartum unit who gave birth 12 hours ago. Because this is her first child, which of the following goals by the nurse is most appropriate? Early discharge for the mother and newborn Rapid transition into her role of being a parent/caretaker Minimal need for expression of her feelings now Effective education of both parents before discharge

effective education of both parents before discharge

Which of the following would the nurse assess as indicating positive bonding between the parents and their newborn? Holding the infant close to the body Having visitors hold the infant Buying expensive infant clothes Requesting that the nurses care for the infant

holding the infant close to the body

While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be the priority?

massaging her fundus

an inflammation of the breast is termed

mastitis

the postpartum womans bladder should be

nonpalpable

the ballard scoring system evaluates newborns on which two factors

physical maturity and neuromuscular maturity

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

place a hand gently on the fetal head to guide birth.

A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate?

providing a comfortable environment with dim lighting

A postpartum woman reports hearing voices and says, "The voices are telling me to do bad things to my baby." The clinic nurse interprets these findings as suggesting postpartum:

pyschosis

most common causes of delayed postpartum hemorrhage include:

retained placental fragments, intrauterine infection, and fibroids

A nurse is preparing to administer erythromycin ointment to a 30-minute-old newborn. What will the nurse do first?

review the HCP's order

lochia typically begins as

rubra

pulmonary embolism is the major cause of maternal mortality due to

the increased clotting factors and risk for DVT which can lead to pulmonary embolism

A client with a pendulous abdomen and uterine fibroid tumors has just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?

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

a soft, boggy uterus that deviates from the midline suggests a full bladder interfering with uterine involution

true

an apgar score of 8 or better is a normal finding

true

immediately after birth, a newborn's mouth is suctioned first, then the nose

true

post term gestation is the most common reason for inducing labor

true

pulmonary embolism is a major cause of maternal mortality

true

the nurse uses leopold maneuvers to identify any deviations in fetal presentation or position

true

the postpartum woman's bladder should be nonpalpable

true

The nurse documents that a newborn is post-term based on the understanding that he was born after: 38 weeks' gestation 40 weeks' gestation 42 weeks' gestation 44 weeks' gestation

42 weeks

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

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

whats is a normal % of body weight that a newborn will experience the first few days after birth

5-10% of their original body weight

a mother choosing to breastfeed requires an additional ________ calories per day

500

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly.

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

administer oxygen by mask

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

assess client's uterine tone, monitor client's vitals, get a pad count

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

encourage the parent to burp the newborn to get rid of air

postpartum danger signs

fever>100.4, change in color or amount, color if lochia, vs changes, blurred vision, headache, calf pain with dorsiflexion, edema, redness or discharge at episiotomy of bladder, SOB, dpression

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

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

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

harlequin sign rationale: Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite.

when teaching a new mother about breastfeeding, the nurse is correct when providing what instructions?

help the mother initiate breastfeeding within 30 minutes of birth, encourage breastfeeding of the newborn on demand, place baby in uninterrupted skin-to-skin contact with the mother

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

her blood pressure is below 140/90 mm Hg rationale: methylergonovine elevates blood pressure. it is important to assess that is not already elevated.

the nurse would anticipate a cesarean birth for a client who has which active infection present at the onset of labor?

herpes simplex virus hepatitis, toxoplasmosis, HPV would not be cause

the major purpose of the first postpartum homecare visit is to: Identify complications that require interventions Obtain a blood specimen for PKU testing Complete the official birth certificate Support the new parents in their parenting roles

identify complications that require interventions

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

no it is the moro reflex

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

normal finding

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior

lochia alba

occurs after day10-2 weeks when this stops cervix is closed

lochia serosa

occurs day 4-10

define pathologic jaundice

occurs in 1st 24 hours after birth and is usually attributed to a maternal/fetal blood incompatability

a decrease in the amount of amniotic fluid to less than 500ml is termed _____

oligohydrminos

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

one fingerbreadth below the umbilicus rationale: After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours

phenylketonuria

when does cardiac output return to nonpregnant values

usually within 2 weeks after birth

The nurse is reviewing the medical record of a woman for whom induction of labor is being considered. The nurse notes the following: Cervical dilation 4 cm Effacement 60% 0 Station Soft cervix Anterior cervical position Based on this information, which Bishop score would the nurse assign?

10 rationale: For each parameter listed, a score of 2 would be given, leading to a total Bishop score of 10. A score of 2 is given for cervical dilation of 3 to 4 cm, 60% to 70% effacement, -1 or 0 station, soft cervical consistency, and anterior position of the cervix. A score of 0 would be given for a closed cervix, 0% to 30% effacement, -3 station, firm cervix, and posterior position. A score of 1 would be given for cervical dilation of 1 to 2 cm, 40% to 50% effacement, -2 station, medium cervical consistency, and midposition of the cervix. A score of 3 would be given for cervical dilation of 5 to 6 cm, 80% effacement, +1 or +2 station, a very soft cervix, and anterior cervical position.

A newborn weighing 5 lb (2250 g) needs to eat 3 oz (90 ml) of formula every 3 hours. To meet this goal, how many ounces of formula per day will the parent need to feed the newborn? Record your answer using a whole number.

24 rationale: Feeding every 3 hours equates to 8 feedings per day. 3 oz × 8 = 24 oz. This can also be calculated in milliliters and converted back into ounces. 90 ml × 8 = 720 ml.

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

Have the client void, and then massage the fundus until it is firm.

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

Hep B

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

assess fetal heart sounds

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

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

the nurse administers a single dose of vitamin K IM to a newborn after birth to promote

blood clotting

Which of the following lab values need to be monitored by the nurse when providing care for a large for gestational age infant?

blood glucose

which measurement best describes delayed postpartum hemorrhage?

blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth

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

blood sugar rationale:

postpartum __________ are usually self-limiting and require no formal treatment other than support and reassurance

blues

A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client?

body secreting the excess fluids form pregnancy

a breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?

breastfeed the infant every 2-4 hours on demand

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

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

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?

difficult to separate clots rationale: If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

fathers bonding with the newborn is called _______

engrossment

A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?

fetal heart tones

When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as:

fetopelvic disproportion

the uterus returns to its normal size through a process called _____

involution

________ is the drug of choice to prevent seizures in the woman with severe preeclampsia

magnesium sulfate

placental perfusion decreases when

placenta ages and goes past the due date. there will be an increased risk of fetal hypoxia and decreased nutrition which could lead to weight loss in utero

oxytocin

secreted by the posterior pituitary in response to infant sucking nipple, cause uterine contractions and letdown reflex

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

severe variable decelerations occur and are due to cord compression

The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?

use McRoberts Maneuver rationale: McRoberts maneuver intervention is used with a large baby who may have shoulder dystocia and requires assistance.

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

use the sealed and chilled milk within 24 hours

A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement?

The parents are beginning to demonstrate positive grieving behaviors.

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

cervix dilates 1 cm per hour

When assessing the following women, which would the nurse identify as being at the greatest risk for preterm labor?

client with history of preterm birth

_______ involves the transfer of heat from one object to another when the two are in direct contact with eachother.

conduction

when getting out of bed for the first time a post-partum pt may feel ____ and experience ______. the best intervention for the nurse at this time is _______

dizzy orthostatic hypotension assist the pt when she gets out of bed for the first time dangling the pt for a few minutes before she stands is also a good practice

Which of these activities would best help the postpartum nurse to provide culturally sensitive care for the childbearing family? Taking a transcultural course Caring for only families of his or her cultural origin Teaching Western beliefs to culturally diverse families Educating himself or herself about diverse cultural practices

educating herself about diverse cultural practices

In dealing with parents experiencing a perinatal loss, which of the following nursing interventions would be most appropriate? Sheltering the parents from the bad news Making all the decisions regarding care Encouraging them to participate in the newborn's care Leaving them by themselves to allow time to grieve

encouraging them to participate in the newborn's care

______ or swelling of the maternal breast tissue may occur usually 2-4 days after birth

engorgement

immediately after childbirth in the recovery area, the nurse observes the mother's partner's fascination and interest in the new son. This behavior is often termed:

engrossment

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

epstein pearls

a women typically experiences tachycardia after delivery

false

during the first 24 hours postpartum, heat is used to provide perineal comfort

false

intravenous anticoagulant therapy to treat thrombotic conditions involves the use of warfarin

false

thromboembolism leads to thrombophlebitis

false

After the nurse provides instructions to a postpartum woman about postpartum blues, which statement would indicate understanding of it? I will

feel like laughing one minute and crying the next minute

A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information?

forceps birth, labor induction with oxytocin, and labor of 1 1/2 hours Factors that increase a postpartum woman's risk for postpartum hemorrhage include: precipitous labor of less than 3 hours, labor induction, use of operative procedures such as forceps, and prolonged third stage of labor (greater than 30 minutes).

The nurse is preparing discharge instructions for a client who has developed endometritis after a cesarean birth. As the client is to be discharged on antibiotic therapy, which instruction should the nurse prioritize?

handwashing rationale: Handwashing is the best defense against the spread of infections. The client is at a higher risk of developing further infections due to her current situation; handwashing before and after using the restroom and doing perineal care will help prevent an infection from occurring. It will also be important for the woman to wash her hands to ensure the infection is not passed to her infant or other family members. The other options of completing the antibiotics, completing proper perineal care, and getting plenty of rest are also important but not a priority.

In assessing a preterm newborn, which of the following findings would be of greatest concern? Milia over the bridge of the nose Thin transparent skin Poor muscle tone Heart murmur

heart murmur

a prolapse of the uterine fundus to or through the cervix so that the uterus is turned inside out after birth is called uterine

inversion

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

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

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

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

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

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

is an infectious condition involving the endometrium, decidua, and adjacent myometrium

metritis

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 rationale: Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.

The nurse is developing a plan of care for a woman experiencing dystocia. Which of the following nursing interventions would be the nurse's high priority? Changing the woman's position frequently Providing comfort measures to the woman Monitoring the fetal heart rate patterns Keeping the couple informed of the labor progress

monitoring the fetal heart rate patterns

Which finding would lead the nurse to suspect that a newborn is experiencing respiratory distress syndrome?

nasal flaring

immediately after birth what is suctioned

newborns mouth is first then nose

The nurse is explaining phototherapy to the parents of a newborn. The nurse would include which of the following as the purpose?

oxidize bilirubin on the skin

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

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

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

periodic crying and insomnia

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?

place an ice pack

the ____ fontanel is triangular shaped

posterior

the ________ fontanel is triangular

posterior

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:

postpartum depression rationale: Extreme fatigue, feelings of sadness and anxiety, and insomnia are consistent with a diagnosis of postpartum depression. risk factors of this are: low socioeconomic status, low self-esteem, feeling overwhelmed or out of control, and lack of social support. Postpartum blues occurs in the first week after birth. Postpartum psychosis is a psychiatric emergency in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions present following a birth. Postpartum adjustment is a positive coping experience in which the woman transitions to the role of mother.

When implementing the plan of care for a multigravida postpartum woman who gave birth just a few hours ago, the nurse vigilantly monitors the client for which complication?

postpartum hemorrhage

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding

labor is one that is completed in less than 3 hours

precipitous

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

prepare the client for a c-section

The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize?

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

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?

preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify?

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

The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to: Encourage ambulation every 30 minutes Provide pain relief measures Monitor the Pitocin infusion rate closely Prepare the woman for an amniotomy

provide pain relief measures

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

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

The rationale for using a prostaglandin gel for a client prior to the induction of labor is to: Stimulate uterine contractions Numb cervical pain receptors Prevent cervical lacerations Soften and efface the cervix

soften and efface the cervix

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?

sudden SOB rationale: Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.

Which factor might result in a decreased supply of breast milk in a postpartum client?

supplemental feedings with formula

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

swollen, tender, hot area on breast

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temperature rationale: first assess edema, redness, drainage The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

the balance between heat loss and heat production is termed ________

thermoregulation

the abdomen of a newborn typically appears _____ without appearing distended

to protrude

drugs promote uterine relaxation by interfering with uterine contraction

tocolytic

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

using a bulb syringe, suction the mouth then the nose

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

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

when administering an IM injection to a newborn the best muscle to use is the _____. the injection should be administered using a -----g ----inch needle.

vastus lateralis 25-27g 1/2inch

The nurse would be most alert for the development of transient tachypnea in a newborn who:

was born by c-section

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider?

weak and rapid pulse rationale: Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.

the nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?

wear a tight, supportive bra rationale: when trying to dry up milk, the woman should avoid stimulation. she needs to wear tight bras and use ice.

where should fundus be 1-2 hours after birth, 6-12 hours

firm at midline between umbilicus and symphsis pubis firm at the umbilicus uterus should involute 1cm daily

_________ exercises help to strengthen the pelvic floor muscles.

kegel

The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 3-in (7.5-cm) lochia stain. This amount should be documented as which type?

light rationale: Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-in (2.5- to 5-cm) stain, and light or small an approximately 3- to 4-in (7.5- to 10-cm) stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What findings by the nurse would be expected?

light pink or brown lochia; uterus 4-5 fingerbreadths below umbilicus

What two elements play the biggest role in becoming a mother after delivery of her newborn?

love and attachment to the child and engagement with the child

The nurse would expect a postpartum woman to demonstrate lochia in which sequence?

rubra, serosa, alba

prolactin

secreted by anterior pituitary promotes milk production

nevus vasculosus is also called

strawberry hemangioma

if the closure of the ductus arteriosus is delayed, what can be heard

a murmur

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

administering oxytocin

Prioritize the postpartum mother's needs 4 hours after giving birth by placing a number 1, 2, 3, or 4 in the blank before each need.

#3 Learn how to hold and cuddle the infant. #4 Watch a baby bath demonstration given by the nurse. #2 Sleep and rest without being disturbed for a few hours. #1 Interaction time (first 30 minutes) with the infant to facilitate bonding.

at what temp should the nurse be concerned for mother

100.4

postpartum hemorrhage is defined as a blood loss of greater than ___________ ml after a cesarean birth

1000

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

Administer oxytocin diluted as a "piggyback" infusion.

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

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

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

Cover the glans generously with petroleum jelly

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

Precocious teeth can occur at birth but we may need to remove them to prevent aspiration.

assess perineum as well as episiotomy site ans c-section incision for REEDA

Redness, Edema, Ecchymosis, Drainage, Approximation of episiotomy or surgical repair

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

S. aureus rationale: transmitted from the neonate's mouth. not harmful to the neonate.

Which technique(s) will the nurse use when administering an intramuscular (IM) injection to a term neonate?

Stabilizing the needle with the nondominant hand Using a quick darting motion Injecting slowly into the anterolateral thigh

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?

The opening of his urethra in located on the under surface of the tip of the penis.

a soft boggy uterus that deviates from the midline suggest

a full bladder interfering with uterine involution

hypercapnia, hypoxia, and _____ resulting from normal labor become the stimuli for initiating respirations in the newborn

acidosis

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

administration of platelet transfusions as prescribed to control bleeding rationale: glucocorticoids, IV immunoglobulins, and IV anti-Rho D are also administered to the client. not NSAIDs

if a pregnant woman is found to be ruebella non-immune during pregnancy, she should receive the immunization _____

after delivery and be advised not to become pregnant for 3 months

_____ refers to the uterine contractions that occur after birth

after pains

Lochia ____ occurs from postpartum days 10-14

alba

involves introducing warmed sterile normal saline or ringer's lactate solution in the uterus

amnioinfusion

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

amniotic fluid embolism

the ____ fonatanel is diamond shaped

anterior

the nurse knows that when breast feeding is successful the following 6 signs will be present:

audible swallowing, milk in babys mouth, breasts feeling softer after nursing, milk leaking from opposite breast, weight gain by newborn and 6 or more wet diapers/day after day 5 or 6

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

avoid empty-calorie foods, breastfeed, increase exercise

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond?

pierced nipple

when does the postpartum period begin

begins with delivery of the placenta

The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal?

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

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?

bright red, raised bumpy area noted above the right eye rationale: needs further investigation to determine whether the hemangioma could interfere with the infant's vision

________ is the antidote for the drug used to treat severe preeclampsia

calcium gluconate

define physiologic jaundice

caused by too many RBCs and immature liver

The nurse is explaining to a postpartum woman 48 hours after her giving childbirth that the after-pains she is experiencing can be the result of which of the following?

contractions of the uterus after birth

uterine changes

contractions stop bleeding at site of placental detachment, the uterine returns to a normal pelvic organ and is no longer palpable after 10 days, the uterus returns to the pre-pregnant size in 5-6 weeks

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis rationale:

A newborn with tracheoesophageal fistula is likely to present with which assessment finding?

drooling from mouth

Because subcutaneous and brown fat stores were used for survival in utero, the nurse would assess an SGA newborn for which of the following? Hyperbilirubinemia Hypothermia Polycythemia Hypoglycemia

hypothermia

A client who was in active labor and whose cervix had dilated to 4 cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of: Hypertonic labor Precipitate labor Hypotonic labor Dysfunctional labor

hypotonic labor occurs in active phase; involves ineffective contractions to evoke cervical dilation and causes secondary inertia

SGA and LGA newborns have an excessive number of red blood cells because of: Hypoxia Hypoglycemia Hypocalcemia Hypothermia

hypoxia

a woman who is bottle-feeding should use ________ packs to alleviate the discomfort of engorgement

ice

a woman who is bottle feeding should use ___ packs and ______ to alleviate the discomfort of engorgment

ice a tight supportive bra

during the first 24 hours postpartum _____ is used to provide perineal comfort

ice pack should be used to reduce inflammation and pain

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:

increasing birth weight

mastitis

infection of the breast tx with antibiotics

the nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss?

placental abruption rationale: the most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive

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

planning a daily special time for the older sibling

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?

uterine rupture