PNE 136/MATERNITY/PREPU/ CHAPTERS 11, 12, 13, 14
A woman who has had a cesarean birth asks you if she will always need to have cesarean births in the future. What would be the nurse's best response? "Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth." "Yes. 'Once a cesarean always a cesarean' is a well-known rule." "There is no way to predict that; it will depend on your individual uterine anatomy." "You will like cesarean birth so much that you will want repeat cesarean births in the future."
"Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth." Explanation: Low transverse incisions ("bikini cut") allow for vaginal birth following cesarean birth because they do not involve the fundal portion of the uterus.
A woman who has had a cesarean birth asks you if she will always need to have cesarean births in the future. What would be the nurse's best response? "There is no way to predict that; it will depend on your individual uterine anatomy." "You will like cesarean birth so much that you will want repeat cesarean births in the future." "Yes. 'Once a cesarean always a cesarean' is a well-known rule." "Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth."
"Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth." Explanation: Low transverse incisions ("bikini cut") allow for vaginal birth following cesarean birth because they do not involve the fundal portion of the uterus.
The nurse cares for a client scheduled for a cesarean birth for a breech presentation. The client requests general anesthesia instead of regional anesthesia for the procedure because of increased anxiety about being awake during the surgery. How does the nurse respond? "There will be a drape placed, so you do not have to worry about seeing the surgery." "The general anesthetic creates a higher risk for your baby, so it is not recommended." "Would you like to have your significant other present for the birth?" "Can you tell me more about what you are concerned about during the surgery?"
"Can you tell me more about what you are concerned about during the surgery?" Explanation: Asking an open-ended question about the client's fears is the best way to understand their reasons for this request, and nursing education can be adapted to address their concerns. General anesthesia for cesarean birth has an increased risk of complications for both the client and newborn, and regional (epidural or spinal) anesthesia is the preferred method. A significant other can be present for the birth with regional anesthesia, and a drape is placed during the surgery; however, the nurse needs to understand the reason for the request before providing further education.
A pregnant client tells the nurse, "Labor and birth sounds so awful. Can't I just schedule a cesarean birth instead?" How will the nurse reply? "Your primary health care provider can review the risks of a cesarean birth to determine if this is okay." "Would you consider taking prenatal classes to learn more about labor and birth before making this decision?" "Our hospital has anesthesiologists on staff who can provide you with an epidural for labor to limit pain." "Can you tell me more about your concerns regarding the labor and birth processes?"
"Can you tell me more about your concerns regarding the labor and birth processes?" Explanation: Because of the risks of a cesarean birth that is not medically indicated, the nurse should explore the reasons behind the client's request to determine if these can be addressed. Asking an open-ended question about the client's concerns is the best way to achieve this. Providing information about pain relief and prenatal classes is not appropriate without assessing the client's concerns further. The nurse can address these concerns and does not need to defer to the primary health care provider.
A newborn has physiologic jaundice. The parents ask why the baby has a yellowish skin color. The most appropriate nursing response is which of the following? "You let us worry about your baby. This is a pretty critical time for her." "I can tell you are worried about your baby. Let's talk about this change in your baby's skin color." "We will be readmitting your child to the hospital. She has a condition known as jaundice." "There is nothing to worry about. Jaundice is very common."
"I can tell you are worried about your baby. Let's talk about this change in your baby's skin color." Explanation: Talking about the parents' concerns helps to explore their worries to assist them. The other responses negate the parents' emotions about the alteration in their baby's health and also indicate that at this time the jaundice is a critical medical issue when there is no indication it is.
The nurse is teaching a new mother how to handle and dress her newborn. Which of the following statements from the mother indicates that teaching was effective? "I should hold my baby close to my body like I'm holding a football." "I should not wrap the baby in a blanket to avoid overheating." "I should fold the diaper above the cord stump." "When I pick up my baby I should turn him over on his stomach first."
"I should hold my baby close to my body like I'm holding a football." Explanation: The mother should hold the baby close to her body to provide security. The "football" hold is a convenient method because it provides a free hand with which to perform additional tasks. It is easier to pick up a newborn when he or she is lying on the back (supine) rather than on the stomach (prone). If the infant is on the stomach, the mother should turn him or her over before picking up, to make the process more secure. The diaper should be folded below the cord stump. The mother should also wrap the baby securely in a blanket. This process is known as swaddling and helps many babies feel more secure.
The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her? "It is all right to suppress the urge to have a stool for a few days to allow my stitches to heal." "I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow." "A good meal for me is cream of chicken soup, cheese toast, and ice cream for dessert." "I will avoid medications for constipation such as psyllium because it can upset the baby's stomach."
"I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow." Explanation: The objective of preventing constipation is to increase the mother's intake of fruits, vegetables, and fiber. The offered meal is comprised of low fiber foods. The mother is discouraged from suppressing the urge to pass stool, although the mother is often frightened it will hurt. Bulk-forming medications such as psyllium are excellent to help the mother not become constipated. There is no problem with the medication interfering with breastfeeding.
A 26-year-old new mother says to her nurse, "I am so disappointed. I gained 25 pounds with my baby. Just what the doctor said I should gain. But after I had my baby I only lost 12 pounds." What is the best response by the nurse? "I know you are anxious to lose all your 'baby fat.' Get yourself on a good diet and you will be down to your original weight in no time." "Remember, it took 9 months for you to gain all this weight. It won't disappear in just a couple of days." "It is normal to lose between 12 and 14 pounds after the baby delivers. You should be back to your pre-pregnancy weight by the time your baby is about 6 months old." "I see that you are bottle-feeding your baby. You would lose your weight faster if you were breastfeeding."
"It is normal to lose between 12 and 14 pounds after the baby delivers. You should be back to your pre-pregnancy weight by the time your baby is about 6 months old." Explanation: Immediately after delivery approximately 12 to 14 pounds are lost with expulsion of the fetus, placenta, and amniotic fluid.
A client who planned an unmedicated vaginal birth at a freestanding birth center is transferred to the hospital for a cesarean birth due to cephalopelvic disproportion. The client says to the nurse, "I feel like such a failure. I could not even give my baby the gentle start that I wanted!" How does the nurse respond? "You should focus on the positive outcome and that you have a healthy baby." "It sounds like you are disappointed by the outcome of the birth. Would you like to talk more about this?" "I am concerned that you might be experiencing postpartum depression. Can we look at a screening questionnaire?" "You tried your best, and sometimes these things just do not turn out the way we expect."
"It sounds like you are disappointed by the outcome of the birth. Would you like to talk more about this?" Explanation: The nurse can provide active listening ("It sounds like you are disappointed") and provide the client with the opportunity to discuss the unexpected outcome of the cesarean birth. Closed-ended statements and reassurances are not helpful for the client at this stage. The client is experiencing normal emotions about an unexpected birth outcome; these are not signs of postpartum depression.
Upon entering the room of the newborn, the nurse notes the newborn is laying on the bed wearing only a diaper while the parents decide on an outfit for the newborn. What response by the nurse is of most importance? "Have you decided on which outfit you will put on the baby to go home?" "I can see you are eager to find the perfect outfit for your baby." "What questions do you have about fabrics that are close to the baby's skin?" "Let me show you how to swaddle the baby while you select the outfit."
"Let me show you how to swaddle the baby while you select the outfit." Explanation: The nurse will instruct the parents on how to swaddle the newborn in a blanket in order to conserve body heat. The newborn is at risk for heat loss when laying in just a diaper. The other responses are appropriate but are not as important as ensuring the newborn maintains body heat.
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "You would probably be more successful if you wrapped him in on a warm blanket." "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" "Let me show you how to calm him down. I've been doing this for many years." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Explanation: Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.
An 20-year-old primipara is getting ready to go home. She had a second-degree episiotomy with repair. She confides in the nurse that she is afraid to go to her postpartum checkup because she is afraid to have the stitches removed. Which reply by the nurse is best? "It is very important for you to go to your checkup visit. Besides, the stitches do not have to be removed." "Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed." "Oh, you must not miss your follow-up appointment. Don't worry. Your midwife will be very gentle." "It doesn't hurt when the midwife takes out the stitches. You will only feel a little tugging and pulling sensation."
"Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed." Explanation: The episiotomy is approximated and repaired using suture that is gradually absorbed by the body
An immediate postpartum parent asks if it is possible to have rooming-in with the newborn. How should the nurse respond to this client's request? "Rooming-in is helpful in allowing you to have more contact with your newborn." "It is not such a good idea to put all this responsibility on you as a first-time parent." "It all depends on whether you are planning to breastfeed." "It would be better for you to rest for the first 3 days so you will be ready when you go home."
"Rooming-in is helpful in allowing you to have more contact with your newborn." Explanation: The more time a postpartum parent has to spend with the newborn, the sooner the parent can become better acquainted with the newborn, feel more confident in the ability to care for the newborn, and more likely form a sound parent-child relationship. Rooming-in is when the parent and child are together 24 hours a day. Rooming-in does not depend on whether the parent is planning to breastfeed the newborn. Rooming-in helps the new parent become confident in the abilities to care for the newborn. Resting for 3 postpartum days is not recommended.
A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? "The baby's sucking releases a hormone that causes the uterus to contract." "Your body is responding to the events of labor, just like after a tough workout." "Your uterus is still shrinking in size; that's why you're feeling this pain." "Let me check your vaginal discharge just to make sure everything is fine."
"The baby's sucking releases a hormone that causes the uterus to contract." Explanation: The woman is describing afterpains, which are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breastfeeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.
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? "He has normal male genitalia." "He has fluid in the scrotal sac." "His testicles have not descended into the scrotal sac." "The opening of his urethra in located on the under surface of the tip of the penis."
"The opening of his urethra in located on the under surface of the tip of the penis." Explanation: The term "hypospadias" refers to the urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis). There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.
A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? "We should clean the skin with soap and water after each bowel movement." "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "It is best practice to change the diaper every 2 to 4 hours, even during the night." "We will fold down the front of her diaper under the umbilical cord until it falls off."
"We will fold down the front of her diaper under the umbilical cord until it falls off." Explanation: In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.
A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching? "The newborn needs to be held after being swaddled." "It is best if you use the same blanket each time for swaddling." "Wrapping the newborn too tightly can impair breathing." "Newborns swaddled frequently may not respond to this comfort measure."
"Wrapping the newborn too tightly can impair breathing." Explanation: Swaddling is a useful measure to comfort a fretful newborn. The only identified problem is that the newborn can become too tightly wrapped, leading to respiratory compromise and breathing difficulties. Swaddling reduces the need to be held, there is no risk of the newborn not responding to it after being swaddled in the past, and the parent does not have to use the same blanket every time.
A nursing student has learned that cervical readiness is generally a prerequisite for successful labor induction. The student correctly uses which of the following terms to describe a cervix favorable for induction? "eager" cervix "ripe" cervix "willing" cervix "ready" cervix
"ripe" cervix Explanation: Ripening occurs when the cervix receives a higher content of water and more blood flow, causing it to become softer. These changes in the cervix allow it to stretch and thin in response to labor contractions. The stretching and thinning of the cervix enables the fetus to pass from the uterus into the vagina during childbirth.
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? 99.1ºF (37.3ºC) at 12 hours postbirth and decreases after 18 hours 100.1ºF (37.8ºC) at 24 hours postbirth and decreases the second postpartum day 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum
100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum Explanation: A temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.
The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention? 53 mg/dL (2.94 mmol/L) 70 mg/dL (3.89 mmol/L) 30 mg/dL (1.67 mmol/L) 90 mg/dL (5.00 mmol/L)
30 mg/dL (1.67 mmol/L) Explanation: Blood glucose levels less than 50 mg/dL (2.77 mmol/L) is indicative of hypoglycemia in a newborn infant and should be further evaluated and/or treated depending on the individual situation.
A newborn at 1 minute of life is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry, and grimaces. What Apgar score would the nurse assign this infant? 6 7 8 9
6 Explanation: According to the Apgar criteria, acrocyanosis is scored as 1, HR over 100 is scored as 2, grimace is scored as 1, some flexion is scored as 1, and a weak cry is scored as 1. This totals 6 for the 1-minute Apgar score.
A newborn at 1 minute of life is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry, and grimaces. What Apgar score would the nurse assign this infant? 6 9 8 7
6 Explanation: According to the Apgar criteria, acrocyanosis is scored as 1, HR over 100 is scored as 2, grimace is scored as 1, some flexion is scored as 1, and a weak cry is scored as 1. This totals 6 for the 1-minute Apgar score.
A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do? Ask the woman to bring the infant back when the doctor finishes the examination. Ask how long the infant will be gone since her next feeding is in 30 minutes. Call the nursery to confirm the doctor does indeed need this infant at this time. Ask to see the woman' hospital identification badge.
Ask to see the woman' hospital identification badge. Explanation: The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue.
A 35-year-old P1001 has been admitted for a scheduled repeat cesarean. As the nurse prepares the client for surgery, what is the best way to begin preoperative teaching? Ask her husband, who is fearful and anxious, to wait outside. Wait until the physician and the anesthesiologist have completed their history and assessment, so the teaching can be more focused and directed. Start by going over the risks of cesarean so she has enough time to go over each one. Assess how much the woman already knows about cesarean.
Assess how much the woman already knows about cesarean. Explanation: It is best for the nurse to assess the situation before beginning postoperative teaching. This client may already have a lot of knowledge because she has had a previous cesarean birth. It is not necessary to wait for the physician and the anesthesiologist to complete the history. Focusing on the risks may contribute to fear and anxiety. Teaching can often help to alleviate fear.
The nurse assists while a pregnant client has an amniotomy. Which action should the nurse take immediately at the conclusion of the procedure? Provide clean gown and linens for the client. Assess the fetal heart rate. Adjust the intravenous fluid infusion rate. Assist the client to wash the perineum.
Assess the fetal heart rate. Explanation: Amniotomy is the artificial rupturing of membranes during labor. A disadvantage of amniotomy is it puts a fetus momentarily at risk for cord prolapse if a loop of cord escapes into the vagina with the fluid. Always measure the fetal heart rate immediately after the rupture of membranes to determine this did not occur. The nurse can assist the client with washing and applying a clean gown and linens after the fetal heart rate is assessed. The client may or may not have an intravenous infusion at this time.
The maternal health nurse assists the birth attendant in a forceps-assisted birth. After the birth of the infant, what is the nurse's priority? Assess the mother for bleeding. Assess the infant for trauma. Increase the rate of oxytocin. Apply supplemental oxygen to the mother.
Assess the infant for trauma . Explanation: A forceps-assisted birth may cause trauma to the infant and the nurse's priority is to assess the infant for signs of trauma. Assessing the mother for bleeding is important; however, the birth attendant assesses for bleeding immediately after birth while the nurse is assessing the newborn. The mother may or may not require supplemental oxygen and this action is not the priority. Pitocin is typically increased immediately after birth to promote uterine involution; however, this is not the priority action.
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? Temperature Heart Rate Respiratory Rate Blood Pressure
Blood Pressure Explanation: The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? Heart Rate Temperature Blood Pressure Respiratory Rate
Blood Pressure Explanation: The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).
The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action? Assume that the parents refused this medication for their infant. Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn. Administer an oral dose of vitamin K to the newborn. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.
Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Explanation: Vitamin K is given IM shortly after birth and, if this medication is not documented, the nurse in the newborn nursery must inquire if the medication was given. Vitamin K is given IM, not oral. A nurse can never assume that a required medication was refused just because it was not documented. Also, the nurse would not give the medication without inquiring to see if it had been administered but not documented.
A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Call the primary care provider. Inform the charge nurse. Document the data. Stimulate the neonate.
Document the data. Explanation: The nurse should document the findings as this neonate's assessment is within the normal range. The normal respiratory rate is 30 to 60 breaths/min and should be counted for a full minute when the neonate is quiet. A neonate starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 beats/min). Normal temperature range is between 97.7°F (36.5°C) and 99.5°F (37.5°C).
After the birth of a newborn, which action would the nurse do first to assist in thermoregulation? Put a hat on the newborn's head. Wrap the newborn in a blanket. Check the newborn's temperature. Dry the newborn thoroughly.
Dry the newborn thoroughly. Explanation: Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.
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? Suggest the parent stop the feeding because the newborn is full. Urge the parent to prop the bottle for the rest of the feeding. Encourage the parent to burp the newborn to get rid of air. Instruct the parent to stop feeding for a few minutes and then restart.
Encourage the parent to burp the newborn to get rid of air. Explanation: Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent fussiness by burping them frequently throughout the feeding. Therefore, the best suggestion would be to have the parent burp the newborn. The newborn may or may not be full; the newborn may still be hungry but excess air in the stomach is making the newborn fussy. Feeding is a time for closeness. Propping a bottle interferes with bonding and increases the risk of choking and other problems. Stopping the feeding and then restarting it would do nothing to help alleviate the swallowed air and may contribute to more air being swallowed.
Upon entering the room of the newborn and parents, the nurse notes the diapered newborn is undressed and laying on the foot of the bed while the parents plan which outfit to place on the baby. What is the priority for the nurse? Discuss the various types of fabric and materials used in newborn outfits and clothing. Suggest the parents select an outfit that is not scratchy on the newborn's skin. Explain the need to keep the newborn wrapped or dressed to prevent cold stress. Provide education on how to safely hold the newborn in the parents' arms.
Explain the need to keep the newborn wrapped or dressed to prevent cold stress. Explanation: The nurse will educate the parents to keep the newborn wrapped or dressed to maintain the newborn's temperature and avoid cold stress. The newborn is at risk for heat loss due to convection. The nurse could discuss fabrics and newborn clothing material safety standards, but this education would not be a priority. The newborn does not need to be held all the time to prevent heat loss, but the newborn should be wrapped/dressed and the nurse could offer education on how to safely hold the newborn if needed. Again, this education is not a priority in this situation. A newborn should be dressed in comfortable clothing, but comfortable clothing is not a priority for the nurse.
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Feeding the infant more formula whenever she begins to fuss Swaddling the infant before returning to the crib Rocking and talking to the infant Gently patting or stroking the infant's back
Feeding the infant more formula whenever she begins to fuss Explanation: Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.
The client, G5P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? Gently massage the fundus until it tones up. Put on the call button to summon help. Teach the woman to perform periodic self-fundal massage. Administer oxytocics to prevent uterine atony.
Gently massage the fundus until it tones up. Explanation: After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the client. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.
A husband asks if he can view his wife's cesarean birth. Which of the following reflects a modern policy on this subject? His wife will be in too much pain for him to be comfortable. He can view it if he chooses, especially because his wife will be awake. Surgery is too distressing for fathers to view. Viewing the surgery ruins the surprise of the child's sex.
He can view it if he chooses, especially because his wife will be awake. Explanation: Childbirth should be a shared experience to the maximum extent possible.
The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 g/dl (140 g/L) and hematocrit of 42% (0.42). Which result should the nurse prioritize? Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean Hemoglobin 11 g/dl (110 g/L) and hematocrit 34% (0.34) in a woman who has given birth by cesarean Hemoglobin 12 g/dl (120 g/L) and hematocrit 38% (0.38) in a woman who has given birth vaginally Hemoglobin 13 g/dl (130 g/L) and hematocrit 40% (0.40) in a woman who has given birth vaginally
Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean Explanation: First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 ml of blood lost during the delivery process, the hemoglobin should decrease by 1 g/dl (10 g/L) and the hematocrit by 2%. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 ml to 500 m and for a cesarean delivery approximately 500 mL to 1000 ml. The loss of hemoglobin from 14 gm/dl (140 g/L) to 9 gm/dl (90 g/L) is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 ml of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Determine the newborn's weight. Administer the medication. Assess the newborn for bleeding. Identify the newborn.
Identify the newborn. Explanation: The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Assess the newborn for bleeding. Administer the medication. Identify the newborn. Determine the newborn's weight.
Identify the newborn. Explanation: The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.
The nurse is conducting a prenatal class for new parents illustrating the various functions their newborn should be able to perform. The nurse determines additional teaching is necessary when the group chooses which action as one they will expect their newborn to exhibit? Newborns are usually predictable in the first several hours after birth. An initial period of reactivity is followed by a longer period of decreased responsiveness. Newborns are usually awake in the first 30 minutes following birth and will demonstrate spontaneous Moro and rooting reflexes. In the first few hours after birth, newborns do not typically demonstrate a response to close visual stimuli.
In the first few hours after birth, newborns do not typically demonstrate a response to close visual stimuli. Explanation: Newborn behaviors are predictable after birth. They enter an initial phase of reactivity followed by a longer period of decreased responsiveness and then a second period of reactivity. They respond to visual and auditory stimuli.
Elective induction is when the birth attendant and the pregnant woman agree to the induction of labor without medical indications. What should the birth attendant explain to the woman before she can give informed consent to induce her labor? Induced labors are less painful and progress faster. Induced labor decreases the possibility of cesarean birth. Induced labor can result in higher costs for the delivery. Induced labor decreases the need for interventions during labor and delivery.
Induced labor can result in higher costs for the delivery. Explanation: Simpson and Thorman (2005) caution against elective induction unless the woman understands that elective inductions often result in more interventions, longer labors, higher costs, and possible cesarean birth.
Elective induction is when the birth attendant and the pregnant woman agree to the induction of labor without medical indications. What should the birth attendant explain to the woman before she can give informed consent to induce her labor? Induced labor decreases the need for interventions during labor and delivery. Induced labor can result in higher costs for the delivery. Induced labors are less painful and progress faster. Induced labor decreases the possibility of cesarean birth.
Induced labor can result in higher costs for the delivery. Explanation: Simpson and Thorman (2005) caution against elective induction unless the woman understands that elective inductions often result in more interventions, longer labors, higher costs, and possible cesarean birth.
A client who has been in labor for 20 hours is being prepared for an emergent cesarean birth. Which action will help ensure the client's fluid status during the procedure? Provide a clear liquid tray. Encourage intake with ice chips. Initiate intravenous fluid therapy. Administer an antiemetic as prescribed.
Initiate intravenous fluid therapy. Explanation: A client who enters surgery with a lower than usual blood volume will experience the effect of surgical blood loss more than a client who has a normal blood volume. A client who has had a long labor before a cesarean birth is scheduled may fall into this category, because the client may have had little to eat or drink for almost 24 hours. Intravenous fluid replacement needs to be initiated preoperatively and continued postoperatively to prevent a serious fluid or electrolyte imbalance. Since surgery is imminent, the client should be kept at "nothing by mouth" status, which means no ice chips or clear liquids. An antiemetic is not indicated for the client at this time.
Healthy bonding behaviors are important to note when the nurse is assessing the new family. What statement or action would the nurse consider a warning sign that the mother and infant were not attaching as they should? Mother wants you in the room while she breastfeeds as she is afraid she is not doing it right. Mother cries and says "I have no family nearby and my mother-in-law doesn't like me." Mother states she is concerned about one of her other children not liking the new baby. Mother states she wanted a boy this time, not another girl.
Mother states she wanted a boy this time, not another girl. Explanation: It is important to differentiate between a new parent who is nervous and anxious about her new role and one who is rejecting her parenting role. Warning signals of poor attachment include turning away from the newborn, refusing or neglecting to provide care, and disengagement from the newborn.
On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? No interventions are needed. This will resolve on its own over the next several days. Place a snug cap on the newborn's head to compress the swelling. An ice pack should be placed on the edematous scalp. Have the mother massage the scalp twice daily to reduce the swelling.
No interventions are needed. This will resolve on its own over the next several days. Explanation: This newborn has a caput succedaneum, which is soft tissue swelling that occurs from pressure of the presenting part during labor. No interventions are needed; inform the parents that this should improve over the next several days without treatment.
Infant, born vaginally 39 minutes ago. In warmer. Id band verified. Heart rate: 134 beats/min. Respiratory rate: 38 breaths/min. Temperature: 97.9F (36.6C). Oxygen saturation: 99% on room air. No retractions notes. Noted shivering. Dr. Oehler, pediatrician at bedside. Mother requesting to nurse. The nurse completes the assessment note on the newborn (above). What action will the nurse take next? Obtain a blood glucose level. Instruct the mother to keep the newborn wrapped in a blanket. Offer emotional support to mother. Assess lung sounds.
Obtain a blood glucose level. Explanation: The nurse would note that shivering in a newborn could actually be jitteriness and, thus, could be a sign of hypoglycemia. The nurse will verify the glucose level. The nurse will offer emotional support to the mother and education about keeping the newborn warm, but these are not priority actions. Assessing the lung sounds is also important but when jitteriness or shaking/shivering is noted in a newborn with a stable temperature, the nurse first needs to address the possibility of hypoglycemia.
The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? Newborns usually sleep for 16 or more hours each day. Caregivers need to sleep while the baby is sleeping. The infant may sleep through the night around 2 months of age. Place the infant on the back when sleeping.
Place the infant on the back when sleeping. Explanation: It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority.
A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action? Allowing the mother to cut the cord of the newborn. Laying the newborn in a radiant warmer for 30 minutes followed by the mother holding the newborn for 30 minutes. Wrapping the newborn in a towel and placing it on the mother's abdomen. Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket.
Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket. Explanation: Skin-to-skin (kangaroo) care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding.
Newborn born via cesarean at 1640. ID band verified. Currently in warmer. Temperature: 96.7F (36C). Respiratory rate: 38 breaths/min. Heart rate: 142 beats/min. Pulse oximeter reading is 99% on room air. Assessment via flowsheet. Strong vigorous crying notes. Irritability noted with jitteriness. Warmed room temperature to increase newborn temperature. Cap on. The LPN reviews the note written by the RN (above). What action will the nurse take next? Prepare to obtain the glucose level. Provide humidified oxygen via blow-by. Assess for patency of esophagus. Monitor bilirubin for decreasing levels.
Prepare to obtain the glucose level. Explanation: Jitteriness, irritability, and a low temperature are signs of early hypoglycemia. Thus, the nurse will measure the newborn's glucose level next. The bilirubin will be monitored, but there is nothing in the note suggesting the level is abnormal. The newborn's pulse oximeter reading is normal and oxygen is not needed. Per the note, there is no indication that the esophagus is not patent.
Which nursing intervention is priority for the nursery nurse to complete on a newborn immediately following a cesarean birth? Suction the newborn's airway. Monitor for hypoglycemia. Assess for congenital defects. Maintain a thermoneutral environment.
Suction the newborn's airway. Explanation: The changes in respiration are the greatest challenge for the newborn. This challenge is even greater in newborns born via cesarean birth. The baby must begin breathing immediately after birth. As soon as the cord is clamped, the infant's lungs become the organs of gas exchange. Excess secretions in the airway can block breathing and, if inhaled, can cause aspiration pneumonia. Maintaining the airway is the nurse's priority. Keeping a thermoneutral environment, monitoring for hypoglycemia, and assessing for congenital defects are all important but not a priority.
The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse? Reassess the newborn in 2 hours. Begin supplemental oxygen with a nasal cannula immediately. Calling the provider immediately and report the findings. Take no action because these are normal findings in a newborn.
Take no action because these are normal findings in a newborn. Explanation: The rate, rhythm, and depth of breathing in a newborn are often irregular. Because these are normal findings, no further action is required by the nurse.
What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply. Episiotomy appears edematous Lochia rubra White blood cell count of 28,000/mm3 Temperature of 101.8°F (38.8°C) Fundal height level of one fingerbreadth above the umbilicus
Temperature of 101.8°F (38.8°C) Fundal height level of one fingerbreadth above the umbilicus Explanation: The uterine fundus should be one fingerbreadth below, not above, the umbilicus. Maternal temperature does increase slightly after delivery but 38.8°C (101.8°F) is too high and the doctor needs to be made aware of it. All other findings are normal.
A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect? The infant's jaundice resolves. The infant remains free of infection. The infant's hemoglobin level increases. The infant remains free of bleeding.
The infant remains free of bleeding. Explanation: Vitamin K injections are given to ensure that neonates do not hemorrhage while their immature liver increases production of clotting factors.
The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive? The father holds the newborn en face and talks to her. The mother states that she has her father's eyes. The mother is reluctant to touch the newborn for fear of hurting her. The parents explore the newborn's extremities, counting fingers and toes.
The mother is reluctant to touch the newborn for fear of hurting her. Explanation: New parents are often nervous and unsure of themselves but bonding behaviors normally follow a pattern. Initially, the parents gently touch the newborn with their fingers, and then go to the extremities to inspect them. Making comments about the newborn's similarities in appearance to the parents is also commonly seen. Holding of the newborn in the en face position, where the parent is directly looking at the newborn, is seen in most families. A reluctance to touch the newborn is counterproductive for bonding since bonding relies on the interaction between the parent and the child.
A woman having a cesarean birth will have a low transverse incision ("bikini cut"). Which of the following would the nurse cite as an advantage? Because the cervix is cut, the operation proceeds rapidly. The uterine incision will be vertical. The skin incision will be just above her pubic hair. Because the fundus of the uterus is cut, the infant can be resuscitated rapidly.
The skin incision will be just above her pubic hair. Explanation: A low cervical incision provides the best access to the fetus and the best cosmetic appearance to the mother.
What should the nurse expect for a full-term newborn's weight during the first few days of life? There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%.
There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. Explanation: The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life.
Which reason explains why women should be encouraged to perform Kegel exercises after birth? They assist with lochia removal. They promote blood flow, enabling healing and muscle strengthening. They assist the woman in burning calories for rapid postpartum weight loss. They promote the return of normal bowel function.
They promote blood flow, enabling healing and muscle strengthening. Explanation: Exercising the pubococcygeal muscle increases blood flow to the area. The increased blood flow brings oxygen and other nutrients to the perineal area to aid in healing. Additionally, these exercises help strengthen the musculature, thereby decreasing the risk of future complications, such as incontinence and uterine prolapse. Performing Kegel exercises may assist with lochia removal, but that isn't their main purpose. Bowel function is not influenced by Kegel exercises. Kegel exercises do not generate sufficient energy expenditure to burn many calories.
The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time? Within 12 hours Within 72 hours Any time prior to discharge Within one hour
Within one hour Explanation: Within the first hour after birth, an antibiotic ointment must be placed in the newborn's eyes to prevent ophthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia.
The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time? Any time prior to discharge Within 12 hours Within 72 hours Within one hour
Within one hour Explanation: Within the first hour after birth, an antibiotic ointment must be placed in the newborn's eyes to prevent ophthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia.
The night shift LPN is checking on a woman who had a cesarean birth with spinal morphine injection anesthesia early that morning. The nurse counts a respiratory rate of 8 per minute. What should the nurse do first? call the anesthesiologist from the room for orders administer naloxone per the preprinted orders awaken the woman and instruct her to breathe more rapidly perform bag-to-mouth rescue breathing at a rate of 12 per minute
administer naloxone per the preprinted orders Explanation: Have naloxone readily available. The anesthesiologist orders naloxone administration if the respiratory rate falls below 10 to 12 per minute.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying warm compresses restricting fluids applying ice administering bromocriptine
applying ice Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: lose more body heat when they sweat than adults. are unable to shiver effectively to increase heat production. have a smaller body surface compared to body mass. have an abundant amount of subcutaneous fat all over.
are unable to shiver effectively to increase heat production. Explanation: Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.
What is the Bishop score?
assesses and rates cervical favorability and readiness for induction of labor. a score above 8 is good. If 6 or below you would need to contact physician before preceding with induction
What are the range and signs of hypoglycemia in a newborn?
below 50 is low Explanation: A healthy newborn's blood glucose level is typically between 40 and 60 mg/dl during the first 24 hours following birth. Levels below 40 mg/ml suggest hypoglycemia.
A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? postpartum gestational hypertension infection diabetes bleeding
bleeding Explanation: Blood pressure should also be monitored carefully during the postpartum period because a decrease in BP can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartum gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.
In caring for the newborn the nurse recognizes that which finding is abnormal and will require immediate attention? respiratory rate less than 60 breaths per minute heart rate of 110 to 150 beats per minute (BPM) blood glucose level less than 40 mg per 100 ml of blood hemoglobin 15 to 18 grams per 100 milliliters of blood
blood glucose level less than 40 mg per 100 ml of blood Explanation: Blood glucose levels less than 40 mg per 100 mg of blood suggest hypoglycemia in neonates. The normal respiratory rate for infants at rest is 30 to 60 breaths per minute. Heart rate in infants is usually in the range of 110 to 150 bpm. Hemoglobin levels in neonates are normally in the range of 15 to 18 g per 100 ml of blood because they have an increased blood volume.
The nurse is providing care for a 10 lb, 2 oz newborn (4,590 g) who is three hours old. The infant begins to display signs of hypoglycemia. The nurse does a heel stick to obtain the infant's blood glucose level. At which of the following blood glucose levels would the nurse treat the infant for neonatal hypoglycemia? blood glucose of 35 mg/dl (1.94 mmol/L) blood glucose of 65 mg/dl (3.61 mmol/L) blood glucose of 45 mg/dl (2.50 mmol/L) blood glucose of 55 mg/dl (3.05 mmol/L)
blood glucose of 35 mg/dl (1.94 mmol/L) Explanation: A healthy newborn's blood glucose level is typically between 40 and 60 mg/dl during the first 24 hours following birth. Levels below 40 mg/ml suggest hypoglycemia.
When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation? profuse sweating deep red, fleshy-smelling lochia voiding of 350 cc blood pressure 90/50 mm Hg
blood pressure 90/50 mm Hg Explanation: In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood pressure and cardiac output are not expected changes during the postpartum period. Early identification is essential to ensure prompt intervention. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus? 6 cm below the umbilicus 2 cm below the umbilicus cannot be palpated 10 cm below the umbilicus
cannot be palpated Explanation: By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
A nurse manager is conducting an in-service education program on cesarean birth for the labor and delivery staff of the facility. After teaching the class, the nurse manager determines that the teaching was successful when the students identify which factor as an indication for cesarean birth? Select all that apply. cervical cerclage longitudinal fetal lie active genital herpes gestational diabetes multiple gestation
cervical cerclage multiple gestation active genital herpes Explanation: Indications for cesarean birth include cervical cerclage, multiple gestation, and active genital herpes. A transverse fetal lie or breech presentation would be an indication. Gestational diabetes may or may not be an indication.
The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method? radiation conduction convection evaporation
conduction Explanation: Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. An example of this is when the infant is placed on a cold scale. Heat loss by convection happens when air currents blow over the newborn's body. An example of this is when the infant is left in a draft of cool air. Evaporative heat loss happens when the newborn's skin is wet. Heat loss also occurs by radiation to a cold object that is close to but not touching the newborn.
The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply. intravenous immune globulin G hepatitis B vaccination hepatitis B immune globulin hepatitis A vaccination
hepatitis B vaccination hepatitis B immune globulin Explanation: Newborns whose mothers have a positive HBsAg must receive a hepatitis B immunization as well as hepatitis B immune globulin for the prevention of hepatitis B in the newborn. IVIG is not specific for hepatitis B prevention. Hepatitis A vaccination will not prevent hepatitis B in the newborn.
A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response? promotes uterine involution improves pelvic floor tone reduces lochia alleviates perineal pain
improves pelvic floor tone Explanation: Muscle clenching perineal exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.
The nursing instructor is conducting a class presenting the various aspects of a cesarean birth. The instructor determines the class is successful after the students correctly choose which complication as the most common postoperative complication? laceration of the uterine artery thrombosis infection pneumonia
infection Explanation: Infection is the most common postoperative complication. Laceration of the uterine artery is an intraoperative complication. Pneumonia and thrombosis are also potential postoperative complications but not as common as infection.
To prevent tearing of the perineum of a client during birth, a physician performs a mediolateral episiotomy. The nurse recognizes that an advantage of a mediolateral episiotomy over a midline episiotomy is which of the following? easier healing less blood loss less postpartal discomfort lower rlsk for rectal mucosal tear
lower rlsk for rectal mucosal tear Explanation: Mediolateral incisions have the advantage over midline cuts in that, if tearing occurs beyond the incision, the tear will not be directed toward the rectum, creating less danger of a rectal mucosal tear, which can result in loss of sphincter function and fecal incontinence later in life. Midline episiotomies, however, heal more easily, cause less blood loss, and result in less postpartal discomfort.
A nursing student correctly identifies that an episiotomy that extends straight down into the true perineum is which of the following? midline episiotomy unilateral episiotomy mediolateral episiotomy lateral episiotomy
midline episiotomy Explanation: There are two basic types of episiotomy. A midline episiotomy extends straight down to the true perineum, while a mediolateral episiotomy angles to the right or left of the perineum. The others are not types of episiotomies.
A nurse is preparing to teach a client about her potential cesarean birth and explains the possible incisional locations. Which information should the nurse include when pointing out the most common type of incision is the low transverse method? facilitates rapid access to the fetus minimizes blood loss extensive adhesions involving the bladder provides for immediate maternal hysterectomy
minimizes blood loss Explanation: The lower segment is the thinnest portion of the uterus with the least vascular activity, and an incision at this site minimizes blood loss. Facilitating rapid access to the fetus, extensive adhesions involving the bladder, and need for immediate maternal hysterectomy are reasons for a vertical incision directly into the wall of the uterine body to be chosen, and not for a transverse incision. The vertical incision is often chosen in emergency cases, where the low transverse is most often used in planned cesarean births.
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 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Explanation: 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 completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? acrocyanosis abdominal breathing respiratory rate of 54 breaths/minute nasal flaring
nasal flaring Explanation: Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.
The LPN/LVN reviews the notes made by the RN during the newborn assessment (above). What assessment finding informs the nurse that the newborn is conserving heat naturally? newborn's skin color newborn's respiratory rate newborn's heart rate newborn's position
newborn's position Explanation: Newborns naturally assume a flexed fetal position to conserve heat by reducing the amount of exposed skin. The other assessment findings are indicative of a newborn who is not experiencing complications such as cold stress, but they do not promote heat conservation.
On inspection, the nurse notes that a newborn has a normal newborn head/body proportion. This proportion for the head is: one-half his total length. one-fourth his total length. one-sixth his total length. one-eighth his total length.
one-fourth his total length. Explanation: Newborn heads are large in proportion to their body, or one-fourth of their total length.
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? estrogen prolactin progesterone oxytocin
oxytocin Explanation: Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin, which causes lactation.
The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments? perineum breasts lower extremities respiratory status
perineum Explanation: Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.
The nurse notes the listed assessment findings in a newborn. Which finding correlates with a glucose level for a newborn is 39 mg/dl (2.16 mmol/l). strong cry heart rate of 142 beats/min poor feeding elevated temperature
poor feeding Explanation: The nurse will further assess the newborn for signs of poor feeding, which is an early sign of low glucose. Normal newborn glucose levels range from 45 mg/dl (2.5 mmol/l) to 126 mg/dl (7.0 mmol/l). The newborn's heart rate is normal. Normal newborn heart rate ranges from 100 beats/min to 205 beats/min while awake. The temperature may be decreased, not elevated.
The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition? postpartum psychosis postpartum depression postpartum blues anxiety disorders
postpartum depression Explanation: The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? trauma to pelvic muscles urinary overflow postpartum diuresis urinary tract infection
postpartum diuresis Explanation: The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
Eight hours after a cesarean section, a postpartum woman is having heavy lochia. She informs the nurse, who suspects which of the following causes? another cause other than the birth normal for a cesarean section infection postpartum hemorrhage
postpartum hemorrhage Explanation: During cesarean birth, the surgeon thoroughly cleans inside the uterus. Therefore, lochia is less than after a vaginal delivery. If lochia flow is moderate or heavy, it could indicate a postpartum hemorrhage.
Eight hours after a cesarean section, a postpartum woman is having heavy lochia. She informs the nurse, who suspects which of the following causes? normal for a cesarean section postpartum hemorrhage infection another cause other than the birth
postpartum hemorrhage Explanation: During cesarean birth, the surgeon thoroughly cleans inside the uterus. Therefore, lochia is less than after a vaginal delivery. If lochia flow is moderate or heavy, it could indicate a postpartum hemorrhage.
The nurse in the labor and delivery unit is performing a focused assessment on a client who is 2 hours postpartum. Assessment reveals a headache 3 out of 10 on a scale of 0 to 10. Vital signs: temperature, 99.1°F (37.3°C); heart rate, 101 beats/min; blood pressure, 87/58 mm Hg; capillary refill time, less than 3 seconds. Client reports a small gush of blood the first time out of bed to ambulate to the bathroom. Three perineal pads have been saturated since birth. Complete the following sentence(s) by choosing from the lists of options. The client is at highest risk for developing
postpartum hemorrhage Evident by 3 perineal pads saturated since birth and bloof pressure 87/58 mm Hg
A primigravida whose baby is presenting breech is scheduled to have a cesarean birth. Which of the following would you prepare her for postoperatively? presence of an indwelling catheter bed rest for the first 4 days separation from her infant for 72 hours insertion of a nasogastric tube
presence of an indwelling catheter Explanation: Because the bladder is handled during surgery, it may not empty well following surgery, necessitating an indwelling catheter.
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? radiation, convection, and conduction nonshivering thermogenesis sweating and peripheral vasoconstriction lack of brown adipose tissue
radiation, convection, and conduction Explanation: Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.
The physician has just examined the patient and determined that she requires a cesarean birth. He notifies the nurse that he will be doing a low cervical vertical incision into the uterus. The nurse knows that the physician has chosen this type of incision over the classical incision because the low cervical vertical incision: reduces the risk of uterine rupture. is less complicated to perform. has a lower risk of maternal injury. is larger than a classical incision and will allow for easier delivery.
reduces the risk of uterine rupture. Explanation: The incision in the low cervical vertical incision is smaller than a classical incision. The low cervical vertical incision is more complicated to perform and has a higher risk of maternal injury. The low cervical vertical incision reduces the risk of uterine rupture.
The nurse is assessing a neonate after a cesarean birth. Which most common complication should the nurse be prepared for? a facial nerve injury hemorrhage shoulder dystocia respiratory distress
respiratory distress Explanation: The most common fetal complications involve miscalculation of dates, which leads to the unintended delivery of a premature fetus and respiratory distress due to retained fluid in the lungs. Hemorrhage and infection are the two most common maternal complications. A cone-shaped head and facial nerve injury are seen in fetuses delivered via vaginal birth. Shoulder dystocia occurs during vaginal births and is an obstetric emergency.
A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn? periodic breathing respirations of 40 breaths/minute symmetrical chest movements sternal retractions
sternal retractions Explanation: Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.
The maternal health nurse is caring for a group of pregnant clients. Which client will the nurse determine is most ready for labor? the client whose Bishop score is 9 today the client who is 41 weeks gestation today the client whose cervical length via endovaginal ultrasound has increased the client whose cervical secretions are negative for fetal fibronectin
the client whose Bishop score is 9 today Explanation: The health care provider may determine cervical readiness using the Bishop score. Five factors are evaluated in the Bishop score: cervical consistency, position, dilation (dilatation), effacement, and fetal station. The higher the score, the greater the chance that induction will be successful. A Bishop score of 9 indicates a "ripe" cervix that is ready for labor. Fetal fibronectin is a protein found in fetal membranes and amniotic fluid. Measuring fetal fibronectin levels in cervical secretions has also been studied for predicting labor readiness. A negative fetal fibronectin may indicate that the client is not yet ready for labor. Although a client who is 41 weeks' gestation is "overdue," this does not indicate that the client's cervix is ready for labor. While measurement of the cervical length via endovaginal ultrasound may be used to determine readiness for labor, labor readiness is manifested by a shortening of the cervical length.
While documenting client care, the nurse notes that a postpartum client is accepting the birth of the child well. What did the nurse most likely observe to come to this conclusion? names the child after a well-loved friend comments that the baby has the most hair of any in the nursery asks the nurse to take a photo of the child turns the face to meet the infant's eyes when holding the baby
turns the face to meet the infant's eyes when holding the baby Explanation: Looking directly at the newborn's face, with direct eye contact or the en face position, is a sign a woman is beginning effective attachment. Naming the child after a well-loved friend, taking a photo of the child, or commenting on the child's hair are not indications that the postpartum client is accepting the birth of the child well.
What is the greatest risk of a vaginal birth following a previous cesarean that was a vertical incision?
uterine rupture
The nurse is assisting with the assessment of a newborn. What assessment finding indicates that the nurse needs to monitor the newborn's respiratory status further? heart rate 142 beats/min psychological jaundice weak cry flexed position
weak cry Explanation: A vigorous cry helps open the small air sacs (alveoli) in the lungs. A weak cry will alert the nurse to further monitor the newborn's respiratory status. A flexed potion is maintained naturally to conserve heat. Physiological jaundice is a concern but not in relation to breathing/oxygenation. The heart rate does not indicate respiratory distress.
The nurse is caring for a woman who has had a baby by cesarean birth. Which of the following would be the most important assessment to make? whether her abdomen is soft or not if she wants to breastfeed or not whether her perineum is edematous if her breasts fill by the third day
whether her abdomen is soft or not Explanation: A tense, "guarded" abdomen is one of the first signs of peritonitis.
