Women's Health HESI

Which gestational period is appropriate for the administration of corticosteroids during preterm labor?

24 to 34 weeks Rationale: If preterm labor occurs during 24-34 weeks of gestation and if labor is unavoidable, corticosteroids should be administered to promote lung maturity.

A pregnant client who is Rh negative visits the prenatal clinic during the first trimester of pregnancy. She is informed by the primary HCP that Rh sensitization is suspected and that Rho(D) immune globulin eventually will be given. At what week of gestation should the nurse explain that the medication will be administered?

28 weeks Rationale: Rho(D) immune globulin administered during the 28th week reduces an active antibody response in an Rh - individual exposed to Rh+ blood. It is difficult to determine whether Rh sensitization has occurred this early in pregnancy.

What drug is responsible for hypoglycemia?

Tolbutamdie Rationale: Tolbutamide is an oral hypoglycemic agent used in to treat type 2 DM. It is known to have teratogenic effects like neonatal hypoglycemia.

On her first visit to the prenatal clinic, a client with rheumatic heart disease asks the nurse whether she has any special nutritional needs. What supplemental in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need?

- iron -folic acid Rationale: B/c pregnant women with heart disease are more likely to have anemia, there may be an additional need for iron and for folic acid. If the pregnant client with heart disease is eating the recommended pregnancy diet and taking prenatal vitamin and mineral supplements, there is no additional need for calcium, Vitamins C, or vitamin B12.

What are the actions of oxytocin?

- promotes milk ejection during lactation - controls uterine bleeding after delivery - induces labor when uterine contractions are weak

A nurse in the high-risk prenatal unit admits a client at 35 weeks gestation with a diagnosis of complete placental previa. What is the most appropriate nursing intervention at this time?

Having oxygen available at the bedside Rationale: If hemorrhage should occur, oxygen is needed to prevent maternal and fetal compromise. A perineal pad is not necessary; close monitoring is required.The client admitted with a complete placenta previa is usually on complete bed rest. It is too soon to discuss the neonatal intensive care unit, and this may be unnecessary anyway.

Which drug may be used to treat postpartum hemorrhage?

Methylergonovine Rationale: Methylergonovine is a drug of choice used to treat postpartum hemorrhage. Clomiphene and menotropins are ovulation stimulants given to induce ovulation in infertile women. Dinoprostone is used to induce cervical ripening and cause termination of a pregnancy.

When discussing dietary needs during pregnancy, a client tells the nurse that milk causes her to be constipated at times. What should the nurse teach the client?

Treat constipation when it occurs and continue drinking milk. Rationale: Unless lactose intolerance is present, the client should drink milk; eating dried fruits and high-fiber foods and increasing fluids and activity will help ease constipation. Substituting cheeses for milk and replacing fat-free or low-fat milk with whole milk can both cause constipation. Megadoses of vitamins can be harmful, and prenatal vitamins are not a substitute for milk.

The nurse is teaching a prenatal class regarding the risks of smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching?

low birthweight Rationale: Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age SGA. Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may results in a SGA neonate; these neonates may experience hypoglycemia.

Which drug has an effect opposite to that of misoprostol?

indomethacin Rationale: Misoprostol is a prostaglandin derivative that is used to induce uterine contractions and promote abortion. Indomethacin is used to maintain pregnancy in preterm labor by inhibiting prostaglandin activity, which is the converse of misoprostol's effects.

A nonstress test NST is scheduled for a patient with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. How should the nurse respond?

"These accelerations are a sign of fetal well-being." Rationale: The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5-15b/m indicates fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test CST or during labor. Variable decelerations are associated with cord compression during CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.

A pregnant client has a positive group beta streptococcus GBS test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan?

"This information will be in your prenatal record; however, please remind your labor and delivery nurse of this finding." Rationale: A client with a positive GBS screening will need to be treated with an IV antibiotic, often PCN or ampicillin, throughout the labor process to prevent transmission of the infection to the neonate. Vertical transfer of GBS to the neonate during labor is associated with higher rates of neonatal mobility and mortality. Untreated, the risk to the neonate is high, and with transmission, the infant will need to be cared for in the NICU. There is no need for an increase in the frequency of prenatal visits or non stress testing as a result of a positive GBS.

A woman at 4o weeks gestation is in active labor. When the client reaches 5 cm dilation, the woman asks for and received epidural analgesia. Once the epidural catheter has been inserted, which assessments and interventions should be performed?

- maintaining IV administration - having oxygen available in case of hypotension - checking the bladder for distention every 2 hours - monitoring fetal heart rate and labor progress per hospital protocol Rationale: Hypotension is a common problem in the client receiving epidural analgesia. IV fluids can help counter this problem and also provide a vehicle for emergency drug administration. Oxygen should be available incase of hypotension as a result of the epidural block or as emergency care should the anesthetic agent migrate upward. B/c sensation below the waist will be compromised, the client may be unaware of bladder distention, a situation that can occur with labor, possibly resulting in trauma to the bladder. Fetal heart tones and the progress of labor should be monitored. The client should be positioned on her side to prevent vena cava syndrome. Labor may be slowed by the epidural, but it is not essential that a woman receiving an epidural have oxytocin to maintain the labor pattern.

The nurse is attempting to determine whether a pregnant woman's membranes have ruptures. Which findings support the conclusion that the membranes have ruptures?

- nitrazine paper turns blue on contact with the fluid - microscopic examination of the fluid reveals ferning Rationale: An alkaline fluid will turn Nitrazine paper blue; amniotic fluid is alkaline. Amniotic fluid demonstrates a ferning pattern, which is visible with a microscope, when placed on a slide. It is not the amount of fluid that is observed, but the characteristics of the fluid that are significant. Amniotic fluid should be clear and may contain white specks of vernix. Yellow coloration indicates that the fluid may be urine. Green fluid is indicative of meconium staining, which is a nonreassuring fetal sign. The odor of amniotic fluid is not similar to that of using. Amniotic fluid has a mild, somewhat fleshy odor.

An infant born at 36 weeks' gestation weighs 4 lb 3 oz (1899 g) and has an Apgar score of 7/9. Which nursing actions will be performed upon the infant's admission to the nursery?

- recording the neonate's vital signs - evaluation of the neonate's health status - keeping the neonate's body warm Rationale: Recording of vital signs is an important part of record keeping for all newborns. All newborns are evaluated on their admission to the nursery. All newborns should be kept warm to maintain a stable boy temperature. The neonate's Apgar scores do not indicate a need for oxygen. Newborns are either breastfed or formula-fed; glucose water is not offered first even for infants with low blood glucose level. In those cases, glucose is give IV.

The nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal?

- tachypnea -exaggerated Moro reflex - prolonged, high-pitched cry -restlessness and excessive activity Rationale: In addition to tachypnea, exaggerated Moro reflex, a prolonged/high-pitched cry, and restlessness/excessive activity, an infant experiencing drug withdrawal has an uncoordinated sucking and swallowing reflex, muscle rigidity with increased muscle tone, and poor sleep patterns. Such infants are often difficult to console.

A woman who abused drugs during pregnancy gave birth to a drug dependent neonate. Which nursing interventions would be beneficial to the neonate?

- to administer smaller doses of the dependent drug - to monitor the neonate carefully and closely - to educate the mother about the risks of drug abuse Rationale: A neonate should be weaned from drug dependence by administering smaller doses of the drugs to which he or she is dependent. These doses should be tapered to avoid withdrawal syndrome. The neonate should be monitored carefully and closely so that the medical team can quickly react to any issues that may arise. The mother should be educated about this risk of drug abuse to prevent further exposure to the drug. Pain relievers administered during delivery may cause respiratory depression. If the dependent drug is stopped immediately, the neonate may develop withdrawal syndromes.

The nurse is assessing her assignment of four postpartum clients. Which conditions increase the risk for postpartum hemorrhage?

- twin birth - over distended bladder - retained placental fragments Rationale: Overdistention of the uterus may lead to delayed or inadequate uterine contractions. An over distended bladder may inhibit uterine contractions. Retained placental fragments inhibit uterine contractions. Clients with ineffective uterine contractions are treated with rest and sedatives; although labor is prolonged, postpartum hemorrhage is not expected. Mild gestation HTN does not interfere with uterine involution.

A client has a diagnosis of unruptured tubal pregnancy. Which assessment findings correlate with this diagnosis?

- unilateral abdominal pain - Hx of STIs Rationale: Pain usually occurs at the location of the affected tube before it has ruptured. STIs are related to pelvic inflammatory disease; the finding that the client has had an STI increases the likelihood that the tubes will be affected, resulting in a tubal pregnancy. A rigid abdomen is not expected if the tube has not ruptured; this finding occurs after the rupture of a tubal pregnancy. Referred shoulder pain occurs as a result of diaphragmatic irritation caused by blood in the peritoneal cavity after a tubal pregnancy ruptures, not before. Ecchymotic blueness around the umbilicus (the Cullen sign) indicates hematoperitoneum in the ruptured intra-abdominal ectopic pregnancy.

A woman who is 34 weeks pregnant is hospitalized for pyelonephritis. Which assessments should the nurse include in the plan of care?

- urine output - temperature - blood pressure - uterine contractions Rationale: Urine output is significant, because the urinary system is involved in the infection. Symptoms of UTIs usually include temperature elevations. A common complication of a UTI/pyelonephritis in pregnancy is preterm labor, so contractions should be monitored. Blood pressure should be monitored to ensure that septicemia, if it occurs, will be identified early.

A client gives brith to a full-term male with an 8/9 Apgar Score. What should the immediate nursing care of this newborn include?

Assessing respirations, keeping him warm, and identifying him. Rationale: Establishing a patent airway, diminishing cold stress, and identifying the newborn are the priorities. Application of the eye prophylaxis and administration of the Vit K are often delated to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspriating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar Score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.

A 7 lb 4 oz (3289 g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe?

By suctioning the mouth before the nostrils Rationale: The mouth is suctioned before the nostrils b/c if the nostrils are suctioned first a reflex gasp may be stimulated, resulting in aspiration of mucus from the mouth. The newborn will be unable to inhale O2 or even breathe if the nose and throat are occluded with mucus. Placing the bulb too far into the mouth may cause trauma or reflex bradycardia. The bulb should be compressed before it is placed in the newborn's mouth; timing of bulb compression is essential, or mucus may be forced farther into the throat.

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primary avoided b/c it can do what?

Cause decreased placental perfusion Rationale: In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduces placental circulation. Although a prolonged course of labor may results if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may results in hypotension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true.

A primigravida at term is admitted to the birthing room in active labor. Later, when the client is dilated to 8 cm, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time b/c pushing can cause which of the following?

Cervical edema Rationale: The head cannot emerge when the cervix is not fully dilated. Pushing in this situation may cause cervical edema, predisposing the client to cervical laceration. A prolapsed cord is usually associated with rupture of the membranes before the head is fully engaged; it occurs more frequently in multiparae. A ruptured uterus may be caused by a hypertonic uterine dysfunction or excessive oxytocin stimulation. A precipitous birth results from sudden, rapid labor and an uncontrolled birth.

During assessment of a newborn in the nursery, the nurse notices a large, dark pigmentation over the buttons of one of the infants. What is the most important interventions?

Checking the medical record regarding this finding at birth. Rationale: Large dark areas of pigmentation over the buttocks are a common birth defect known as Mongolian spots. These hyper pigmented areas can resemble bruising but lessen over time and usually disappear by the time the child reaches school age. The nurse taking care of this infant should check the medical record for documentation of this finding at birth in the medical record. Mongolian spots are not caused by bleeding, trauma, or abuse.

A client in labor is receiving oxytocin (Pitocin) infusion. Which intervention is a priority for the nurse when repetitive late decelerations of the fetal heart rate are observed?

Discontinue the oxytocin infusion Rationale: Treat the immediate potential cause of the decelerations by discontinuing the oxytocin infusion. The infusion should be stopped b/c it is the likely source fo fetal compromise. Additional interventions including administering oxygen, placing client on left side, and monitoring vital signs should be initiated to support both the mother and the unborn child. These interventions are supportive therapy not treatment of the cause.

A primiparous client reports to the maternity unit stating that her contractions are occurring every 5 minutes. Upon further inquiry, the nurse learns that the client has not attended any childbirth classes. A cervical assessment reveals that she is in true labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques?

During the latent stage of the first stage of labor Rationale: During the latent phase of the first stage of labor the client is excited and open to learning. The contractions are not as strong as they are going to be, so the client has time b/w contractions to absorb the nurse's teaching. Contractions are more frequent and stronger in the active phase of the first stage. The increased frequency decreases the client's ability to absorb information. During the active phase of the second stage of labor the client will be bearing down to expel the fetus, and simple breathing techniques are not appropriate. During the transition phase of the first stage the contractions are at their maximum intensity, which inhibits the client's ability to listen.

A client had a 4th Degree perineal laceration during the birth of her neonate. What should the nurse recommend to protect the area from additional trauma?

Eat a high-fiber diet with increased fluid intake. Rationale: Fluid intake and fiber help promote soft stools and defection. Promotion of defection is a priority b/c a 4th degree laceration impinges on the rectal sphincter. Constipation will further traumatize the rectum. Although site baths and anesthetic pads each relieve pain and promote healing, they do not prevent additional trauma. An enema would cause additional trauma to the rectum and is contraindicated.

When changing her newborn's diaper a new mother notes a reddened area on the infant's buttock and reports it to the nurse. How should the nurse best address this mother's concern?

Encourage the mother to cleanse the area and change the diaper more often. Rationale: Frequent cleansing and diaper changes will limit the presence of irritation substances. Having the nurses change the diaper may lower the mother's self-esteem. Powder and lotion will cake and retain moisture in the area. Requesting that the HCP prescribe a topical ointment is a nursing, not a medical, problem.

During the immediate postpartum period, the client with heart disease may experience increased cardiac output with tachycardia. This knowledge should motivate the nurse who is caring for this client to monitor her for what?

Labored breathing Rationale: With the mobilization of extravascular fluid and the rapid decrease in uterine blood flow, the heart of the client with cardiac problem may begin to fail. As the heart fails, the respiratory rate and effort increase in an attempt to maintain oxygen to all body cells. Although the pulse rate is important, the primary assessment should be signs of respiratory distress, such as labored breathing. Signs of heart failure, not hypovolemic shock, might develop if the respiratory distress is not treated. Increased vaginal bleeding is not caused by alterations in cardiac status.

The HCP determines that the fetus is in a breech presentation. Which complication should the nurse monitor this client for?

Nonreassuring fetal signs, indicating prolapse of the cord Rationale: The feet or buttocks are not effective in blocking the cervical opening, and the cord may slip through and become compressed. Rapid dilation and precipitate labor are more likely to occur if the fetus is in a cephalic presentation. Stronger contractions, indicating progression of labor, are an expected occurrence. Uterine inertia may result from fatigue or cephalopelvic disproportion and is not related directly to fetal presentation.

During labor an internal fetal monitor is applied. Which fetal heart rate FHR should most concern the nurse?

One that returns to baseline after a contraction ends. Rationale: A return of the FHR to baseline after a contraction ends is called a late deceleration; it begins after the contraction has started, the lowest point of the deceleration occurs after the peak of the contraction, and the deceleration usually does not return to baseline until after the contraction ends (late recovery). Late decelerations, which are caused by uteroplacental insufficiency, are a sign of a compromised fetus. The FHR does not always drop with a contraction. Beat-to-beat variability indicates a fetus with a healthy nervous system and does not warrant concern. A decrease in fetal heart rate to 110 bpm during a contraction, known as an early deceleration, is a restful of fetal head compression during a contraction; the FHR returns to baseline last the same time that the contraction ends.

A client in labor is having an indwelling urinary catheter inserted. What should the nurse plan to do to prevent late decelerations of the fetal heart rate during this procedure.

Place a rolled towel under the client's right hip Rationale: Elevating the right hip during catheter insertion displaces the uterus to the left. This action improved placental perfusion and prevents supine hypotension caused by pressure on the vena cava with its associated late fetal heart rate decelerations. Placing the feet in stirrups simultaneously helps prevent trauma to ligaments at the time of birth; it is not done when a urinary catheter is inserted. Breathing frequently is contraindicated b/c hyperventilation may result. Adjusting the belts around the client's abdomen does not affect the fetal heart rate.

What action involving client needs may a nurse delegate to an Unlicensed Health Care Worker?

Providing ice chips to a primigravida in early labor per the primary HCP's prescription Rationale: Providing ice chips to a primigravida in early labor per the HCP's prescription does not require clinical knowledge or judgement for safe, effective care. Assessment, discussion of alternative actions, and the use of sterile technique during an invasive procedure all require clinical knowledge and judgement beyond the scope of practice of an unlicensed HCP.

Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of deceleration.

Repositioning the client from side to side Rationale: A deceleration with a rapid descent and ascent to and from the lowest point of the deceleration is a variable deceleration caused by cord compression. Changing the client's position from side to side promotes release of the compression. Oxygen given while the cord remains compressed will not provide fetal oxygenation. Increasing the rate of intravenous fluid administration and elevating the legs are interventions for placental perfusion problems and do not affect cord compression.

The nurse is conducting the admission assessment of a client who is positive for group beta strep GBS. Which finding is of most concern to the nurse?

SROM 3 hours ago Rationale: Rupture of membranes before intrapartum treatment of GBS increases the chances that infection will ascend into the uterus. GBS infection is a leading cause of neonatal mortality and morbidity. Continued bloody show, cervical dilation of 4 cm, and contractions every 4 minutes are all normal findings for a client in labor.

A client delivered a 7 lb 6 oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff bring the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery b/c she has not showered yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother called the nursery and asks if the baby be picked up so she can take a nap. Which behavior is the new mother demonstrating?

Taking in Rationale: During the taking in period, the mother focuses on her needs rather than the baby's. During this period the mother needs to be "mothered" so she can assume the role of mother. The letting go period is when the mother wants to take control and mother the infant. The taking hold period is when the mother is anxious to learn about the infant and how to care for it. This mother shows positive behaviors, including smiling, kissing, and holding. There is no evidence of a failure to bond.

After a client has been in labor for 6 hours at home, and she is admitted to the birthing room. The client is dilated 5 cm and at -1 station. In the next hour her contractions gradually become irregular and are more uncomfortable. Which possibility should the nurse consider first?

The client has a full bladder. Rationale: A full bladder can impede the forces of labor, and so it must be emptied before any further assessment. The client's cervix is dilating, and therefore she is in true, not false, labor. Before the possibility of uterine dysfunction is considered, the client's bladder should be emptied to relieve the pressure of the bladder on the uterus; the client should then be observed to determine whether regular contractions have been resumed.

A client at 41 weeks' gestation is scheduled for a contraction stress test CST. How should the nurse explain a CST result that is interpreted as negative?

The fetus at this time is likely to tolerate the stress of labor; however, the test should be repeated weekly. Rationale: A negative CST implies that placental support is adequate, and the fetus is likely to tolerate the stress of labor should it ensure within the week. Interpretable dates did not show signs of hyper stimulation if the negative result was reported. This is a sign of a NST, which indicates that the fetus is at increased risk. Fetal HR accelerations with movement constitute a negative CST; they are a sign of fetal well-being and do not require a trial induction.

Supplemental O2 is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?

Verifying oxygen saturation frequently to adjust flow on the basis of need Rationale: Determining oxygen saturation identifies the need for oxygen supplementation; prolonged use of oxygen concentrations exceeding those required to maintain adequate oxygenation contributes to the occurrence of retinopathy of prematurity. Preventing dehydration by humidifying the oxygen will not prevent retinopathy of prematurity. The skin does not absorb oxygen; it must enter the lungs through inhalation. Retinopathy of prematurity is caused by a high blood concentration of oxygen, not by exposure of the eyes to oxygen.

The nurse in the birthing unit assesses a primigravida who is at 42 weeks gestation. Fluid is leaking from her vagina, and she is complaining of back pain. Which conclusion is supported by the data that the nurse has collected? Fetal assessment: experiencing early decels; presenting part floating; FHR 140 bpm in right lower quadrant Maternal assessment: cervix 2 cm/70%, streaks of blood from vagina, fetal back in right lower quadrant, contraction every 3-4 mins lasting 30-45 secs Lab results: positive nitrazine test

cesarean birth is anticipated Rationale: A floating fetal head in a primigravida at 42 weeks gestation who is in early labor is suggestive of cephalopelvic disproportion. Enlargement in primigravidas usually occurs before labor begins. A cesarean birth should be anticipated.

A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider regarding breech presentations when caring for this client?

cesarean birth probably will be necessary Rationale: A cesarean birth may be performed when the fetus is in the breech presentation b/c the risk of mobility and mortality is increased. A vertex presentation in the occiput posterior position usually causes back pain. Labor is usually longer with a fetus in the breech presentation b/c the buttocks are not as effective as the head as a dialing wedge. Meconium is a common finding in the amniotic fluid of a client whose fetus is in the breech position, b/c contractions compress the fetal intestinal tract, causing release of meconium.

A client who is at 26 weeks' gestation tells the nurse at the prenatal clinic that she has pain during urination, back tenderness, and pink-tinged urine. A diagnosis of pyelonephritis is made. What is the most important nursing intervention at this time?

checking for signs of preterm labor Rationale: Pyelonephritis often causes preterm labor, leading to increased neonatal morbidity and mortality. Fluids should be increased. The inflammatory process may lead to fever, dehydration, and an accumulation of toxins. Proteinuria occurs with preeclampsia; the client's sign and symptoms are indicative of a kidney infection. A moderate-sodium diet is not relevant to the client's problem.

A man calls the prenatal clinic to ask the nurse when he should bring his wife to the hospital. He says, "The baby is due in 2 weeks, but she thinks it could be earlier. This is our first baby, and we're nervous." The nurse knows that as a nullipara, it would be important for the client to be seen if the contractions do what?

come every 5 minutes for an hr Rationale: Contractions every 5 minutes apart for 1 hr are an indication for true labor. B/c the woman is a nullipara, this is an appropriate response. Contractions that ease when the client walks or are irregular and vary in intensity are signs of false labor. Contractions coming 10 minutes apart for 1 hour in a nullipara are too far apart for true labor. This reading would be appropriate for multiparous woman, whose labor is likely to be shorter and more intense.

While assessing a neonate's temperature, the nurse observes a drop in body temperature. What is the most appropriate reason for this temperature to drop?

decreased non shivering thermogenesis Rationale: Neonates are susceptible to heat loss of cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism's failure may lead to a drop in body temperature. The basal metabolic rate BMR accounts for heat production; an increased BMR may raise the body temperature.

During the second stage of labor the nurse discourages the client from holding her breath longer than 6 seconds while pushing with each contraction. Which complication does this prevent?

fetal hypoxia Rationale: Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal HTN are not caused by prolonged holding of the breath.

Which factor does the nurse conclude is directly related to an infant's survival in the neonatal period?

gestational age and birth weight Rationale: Adaptation to the extrauterine environment is largely dependent on the functional capacity of vital organ systems, which is established during intrauterine development; this is measurable in terms of gestational age and weight. Although the reproductive history of the mother, parenteral health habits, and social class may all influence health, none of these is critical to neonatal survival. Although adequacy of the mother's prenatal care may influence the mother's health and therefore the fetus's health, it is not critical to neonatal survival as are an adequate gestational age and birth weight.

The nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant has what limitation?

has a limited supply of brown fat available to provide heat Rationale: Because neonates are unable to shiver, they use the breakdown of brown fat to supply body heat; the preterm infant has a limited supply of brown fat available for this purpose. An inability to use shivering to produce heat is not specific to preterm neonates; all newborns are unable to use shivering to supply body heat. The breakdown fo glycogen into glucose down not supply body heat. Pituitary hormones do not regulate body heat.

A client's labor as progressed to the point where she is 6 cm dilated; however, the fetal head is not engaged. An amniotomy is performed. After this procedure, the nurse checks the fetal heart rate. What otters nursing action should be performed at this time?

inspecting the perineum Rationale: After the rupture of membranes, the umbilical cord may prolapse if the fetal head does not engage immediately, and this can lead to fetal compromise. The perineal area should be inspected at his time and frequently thereafter for evidence of cord prolapse. Rupture of the membranes does not lead to precipitous birth; it is done to facilitate labor. Rupture of membranes is not associated with maternal blood pressure changes. Increasing the IV rate is appropriate if the client shows signs of dehydration; the data do not indicate this.

A nurse is caring for a client with class III heart disease who is beginning the second stage of labor. For which medical intervention does the nurse prepare the client at this time?

instrument extraction to ease the vaginal birth Rationale: Either the use of forceps or vacuum extraction for the second stage of labor helps decrease the workload of the heart during expulsion, thereby facilitating the vaginal birth. Clients with cardiac problems can give birth vaginally when precautionary measures are instituted; it is preferable to prevent the secondary stress that surgery may impose. Epidural anesthesia is preferred, b/c there is no pain and energy is conserved. Tocolytic agents are used to halt preterm labor. The goal is to progress with labor as quickly as possible.

A client who had tocolytic therapy for preterm labor is being discharged. Which instructions should the nurse include in the teaching plan?

limit daily activities Rationale: Although it has not been proven that bed rest limits preterm labor, it is often recommended. Activities are restricted to bathroom privileges and movement to a daytime resting area. Fluid intake should not be restricted; hydration should be maintained. Monitoring of the urinary protein level is included in the care of a client with preeclampsia, not preterm labor. Deep-breathing exercises have no influence on the development of preterm labor.

A client who is at 38 weeks' gestation is admitted to the birthing unit b/c her membranes ruptured 24 hrs ago and contractions have started. The fetus is in breech presentation. The nurse observes that the amniotic fluid is green. What does the nurse conclude from these findings?

meconium is being expelled with contractions Rationale: In a breech presentation, the pressure of the contractions on the fetus's lower abdomen causes meconium to be expelled into the amniotic fluid with each contraction. Meconium in the amniotic fluids not a sign of a neural tube defect, regardless of fetal presentation. Greenish amniotic fluid does not indicate a compromised fetus if there is a breech presentation. The data do not indicate sins of malodorous amniotic fluid or maternal pyrexia, each of which is indicative of infection.

What breathing technique does the nurse instruct a pregnant woman to use a the fetus's head crown on the perineum?

open glottis Rationale: Breathing with the glottis open prevents the Valsalva maneuver, thereby limiting the strong urge to push and permitting a more controlled birth of the head. A cleansing breath is used at the beginning and end of each contraction. This is more helpful earlier in labor. Coaching a client to hold her breath while bearing down is still common practice; however, it should be discouraged. Closed-glottis pushing increases intrathoracic and cardiac pressure, thereby reduction perfusion of the uterus and placenta. Patterned-paced (pant-blow) breathing is suggested reign the transition phase of the first stage of labor when concentration on other breathing patterns is difficult to maintain.

A nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. What condition does this medication prevent?

ophthalmia neonatorum Rationale: Ophthalmia neonatorum is caused by gonorrheal and/or chlamydial infections present in the vaginal tract. It is preventable with the prophylactic use of an antibiotic ophthalmic ointment applied to the neonate's eyes.

A registered nurse RN is instruction to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients?

oral cavity Rationale: The oral cavity is the preferred site for temperature measurement in adult pts. This site is contraindicated for neonates and unconscious or uncooperative pts. The axilla is a safe site for placing a thermometer in neonates. The temporal artery is indicated for rapid temperature measurement. This site is indicated for premature infants, newborns, and children. The tympanic membrane is indicated in newborns to reduce infant handling and heat loss.

A pregnant client has a history of multiple preterm birth followed by neonatal deaths. Which is the most significant impending sign of danger that the client must be taught to report?

pelvic pressure Rationale: Pelvic pressure or a feeling that the fetus is pushing down is one symptom of preterm labor and should be taught to the client so she may seek care immediately. Leg cramps are not a danger sign of preterm labor; nor is nausea. Fetal movement is not felt until approximately 16 weeks.

A client is admitted to the birthing room in active labor. She is gravid 4 para 3. When she is at 8 cm, her membranes rupture spontaneously. What should the nurse do after assessing the fetal well-being?

perform vaginal exam Rationale: B/c the client is a multigravida, the fetal head may not have engaged in the pelvis. The umbilical cord may prolapse and become compressed as the fetal head descends; immediate intervention is required if the cord has prolapsed. More data are needed before the practitioner is notified. After it is determined that the umbilical cord has not prolapsed and the fetus' HR is within expected limits, documentation may be performed. After it is determined that the umbilical cord has not prolapsed, the client's bedding may be changed.

A newborn is experiencing cold stress while being admitted to the nursery. Which nursing goal has the highest immediate priority?

prevent metabolism of fat stores Rationale: Newborns do not shiver. If the newborn is cold, there is increased brown fat metabolism (non shivering thermogenesis), which increases fatty acid blood levels and predisposes the infant to acidosis. Hypoglycemia and not hyperglycemia will occur b/c the newborn's glycogen reserves deplete rapidly while under cold stress. Although oxygen consumption increases during cold stress, limiting oxygen consumption is not the priority; reducing non shivering thermogenesis is more imperative.

A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed?

progressive dilation and effacement Rationale: AROM (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enahwvng dilation and effacement. Vaginal bleeding may increased b/c of the progression of labor. Amniotomy does not directly affect the FHR. Discomfort may become greater b/c contractions usually increase in intensity and frequency after the AROM.

A client's membranes rupture during labor. The nurse immediately assessed the electronic fetal heart rate. Variable deceleration lasting more than 90 seconds, followed by bradycardia, are observed on the monitoring strip. Which physiologic finding does the nurse suspect is the cause of this abrupt change?

prolapsed cord Rationale: This variable pattern with bradycardia is an ominous sign; it is indicative of a prolapsed cord, or cord compression, which can result in fetal hypoxia. Immediate intervention is required. Fetal acidoses, not fetal heart rate changes, occurs with uteroplacental insufficiency. Early decelerations are associated with head compression and are benign. Late decelerations and tachycardia, not variable decelerations followed by bradycardia, are associated with uteroplacental insufficiency.

A client at 36 weeks' gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and anti seizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are appleid. Which complication of severe preeclampsia requires diligent monitoring of the blood pressure?

stroke Rationale: The likelihood of a stroke increases with a rising blood pressure reading. The degree of hypertension is not associated with hemorrhage. The course of labor is not affected by blood pressure changes except in the presence of abruptio placentae. Fluctuations of BP do not affect the status of clotting factors.

A nurse is assessing a newborn with caput succedaneum. How does the nurse explain the cause of this fetal condition to the new mother?

swelling of the soft tissue of the scalp as a result of pressure during labor Rationale: Caput succadaneum is a diffuse pattern of edema above the periosteum; it results from an even distraction of pressure on the fetal head during labor. Overlap of fetal scalp bones in called molding. Swelling that does not cross the suture line is cephalohematoma, not caput succedaneum; it occurs when the fetal head is pressing on the rim of the pelvis during the birthing process. Accumulation of fluid resulting from a partial blockage of cerebrospinal fluid is hydrocephalus; in hydrocephalus the circumference of the head is larger than expected.

A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client reports that she feels as though she is going to vomit. Which phase of the first stage of labor does the nurse suspect the client has entered?

transition Rationale: The physiological intensification of labor that occurs during transition (8 to 10 cm) is caused by greater energy expenditure and increased pressure on the abdomen; this results in feelings of fatigue, discouragement, and nausea. The latent phase is the earliest phase of labor. It is characterized by cervical dilation and effacement (0 to 3 cm). There are 3 phases in the first stage of labor. The active phase phase lasts form 4 to 7 cm of dilation. There is no distinction b/w early and late active phases.

The nurse in the birthing unit is caring for several postpartum clients. Which factor will increase the risk for hypotonic uterine dystocia?

twin gestation Rationale: Hypotonic uterine dystocia describes an abnormal labor during which the uterus contracts poorly and inadequately, resulting in a difficult birth that may be caused by large or awkwardly positioned fetus(es). A multiple gestation thins the uterine wall by overstitching it; therefore, the efficiency of contractions is reduced. Gestational anemia is physiologic anemia that is benign; although anemia may cause fatigue during labor, it does not affect uterine contractility. Hypertonic contractions will cause increased discomfort, fatigue, dehydration, and increased emotional distress, not hypotonic uterine dystocia. Therapeutic interventions include rest and sedation. Gestational HTN may trigger preterm labor; it does not cause hypotonic uterine dysfunction.

A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse instruct the client to do?

use the pant-breathing pattern Rationale: Panting will slow the process so the nurse can support the head as the baby is born. Pushing will speed the birth, which would result in injury to both mother and and fetus.

The nurse places the fetal and uterine monitors on the abdomen of the client in labor. While observing the relationship b/w the fetal HR and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations?

uteroplacental insufficiency Rationale: Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency.

The nurse is caring for a client in the first stage of labor, and an external fetal heart monitor is in place. What do the tracings indicate?

variable decelerations Rationale: Variable decels are illustrated by a sudden decrease in the FHR below baseline, lasting about 15 secs and then returning to baseline within 2 minutes. These decels are caused by compression of the umbilical cord. If they occur during the first stage of labor, they usually resolve when the mother is repositioned from one side to the other.

A laboring client who is positive for group beta strep GBS is given an initial dose of 2 g of ampicillin at 9AM. According to establishing guidelines for intrapartum management of this client, what should the next dose be?

1 g given at 1 PM Rationale: The established guidelines for intrapartum antibiotic prophylaxis for a client infected with GBS is an initial dose of 2 g followed by a 1 g dose every 4 hours.

A nurse at the prenatal clinic examines a client and determines that her uterus has risen out of the pelvis and is now an abdominal organ. At what week of gestation would the nurse expect this clinical finding?

12th week Rationale: By the 12th week of pregnancy, the fetus and placenta have grown, expanding the size of the uterus. The enlarged uterus extends into the abdominal cavity.

A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate?

cesarean birth Rationale: Immediate birth is necessary to prevent fetal hypoxia and death. Allowing a prolonged labor, inducing labor, or using vacuum extraction in the vaginal birth will increase pressure on the cord, resulting in fetal hypoxia.

Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestation support this conclusion?

increased bloody show, irritability, and shaking Rationale: Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response.

Which hypothalamic hormone helps to treat postpartum uterine atony and hemorrhage?

oxytocin

A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the physiologic mechanism of this therapy?

Breaks down the bilirubin into a conjugated form Rationale: Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Bit K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by the. way of the skin.

A nurse in the newborn nursery is monitoring gan infant for jaundice related to ABO incompatibility. What blood type does the mother usually have to cause this incompatibility?

O Rationale: Mothers with type O blood have anti-A and anti-B antibodies that are transferred across the placenta. This is the most incompatibility, b/c the mother is type O in 20% of all pregnancies. Blood types A, B and AB usually do not present this problem.

Which information should the nurse include in the discharge teaching of a postpartum client?

The prenatal Kegel tightening exercise should be continued Rationale: Kegel exercise may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.

A client at 32 weeks is admitted to the prenatal unit in preterm labor. An infusion of magnesium sulfate is started. What physiologic response indicates to the nurse that the magnesium sulfate is having a therapeutic effect?

a decrease in frequency and duration of contractions Rationale: The purpose of administering magnesium sulfate is to stop preterm labor. It is a tocolytic age that relaxes uterine smooth muscle.

During the second postpartum hour after a long labor and difficult birth, a nurse identifies that the client has heavy vaginal bleeding that does not diminish after fundal massage. The client reports, "I'm so thirsty. May I have some ginger ale?" How should the nurse reply?

"I know this is difficult; however, it's best for you to wait until the bleeding has subsided. I can give you a moisturizer for your lips to relieve the dryness." Rationale: The client should receive nothing by mouth while heavy bleeding continues, because surgical intervention may become necessary. Providing oral fluids at this time is inappropriate and could result in aspiration if surgery becomes necessary. The nurse does not need a prescription to give fluids to postpartum client; the nurse must make an independent judgment regarding the withholding of fluids. Although oral fluids can increase the blood volume, it would be inappropriate to provide fluids while the client is bleeding.

What is the optimal nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?

Assist the client's coach in helping her with the use of breathing techniques Rationale: The client is in the early part of the first stage of labor, and it is important to help the partner with the role of coach. It is not necessary to check the fetal HR every 5 minutes until the 2nd stage fo labor. The first stage of labor is not as stressful for the fetus as the second stage of labor. Birth is not imminent at this time; the client is only dilated 4 cm. Suggesting that there is discomfort may increase anxiety and produce greater discomfort.

While caring for a pregnant client with a body mass index of 32 during labor, the nurse observes that the second stage of labor lasts for about 11 minutes. The nurse also finds that the expected birth weight of the fetus is around 4200 g. Which complication does the nurse anticipate in the neonate after birth?

erb palsy Rationale: Maternal BMI of greater than 30, a second stage of labor lasting less than 15 minutes, and an infant birth weight higher than 4000 g indicates a risk of Erb palsy in the neonate.

A primigravida at 38 weeks of gestation presents to the clinic with a blood pressure of 142/94 mm Hg, edema in all extremities, and a weight gain of 5 lb (2.3 kg) since the previous checkup 1 week ago. The client has delivered and is receiving magnesium sulfate postpartum. What is the priority nursing action during the immediate 4 hours after deliver?

Observing amount of lochia Rationale: Observing the amount of lochia is a priority during the 4 hours after delivery because of the risk of hemorrhage, which normally occurs during the fourth stage of labor, and the increased risk of low platelets because of blood clotting issues that accompany preeclampsia. Monitoring blood pressure is important to help assess for hemorrhage, but it will be expected to decrease. Monitoring urinary output is important because of the client's diuresis and is expected to be above 30 mL/hr. The client would not be breastfeeding while receiving magnesium therapy.

During a routine prenatal office visit at 26 weeks, a client states that she is getting fat all over and that she even needed to buy bigger shoes. What is the next nursing action?

Obtaining the client's weight and BP Rationale: The client's weight and BP help the nurse determine whether an unusual weight gain or an increase in BP has occurred; both of these findings are early signs of preeclampsia. The data suggest a greater-than-expected weight gain. Supporting the client's decision to buy comfortable shoes ignores the possibility that the edema and weight gain are related to preeclampsia. The weigh gain may not be caused by inappropriate dietary intake but rather an underlying pathologic condition.

The postpartum nurse is providing care to four maternal/infant couplets who have all delivered within the past 24 hours. After receiving the handoff report from the off-going nurse, which client is a priority for the nurse to see first?

The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL (90 mcmol/L) Rationale: The appearance of jaundice during the first 24 hours of life or persistence beyond the ages delineated usually indicates a potential pathologic process that requires further investigation. The acceptable range for the newborn heart rate is 110 to 160 beats/min. saturating more than one pad per hour with lochia rubra is a matter of concern because it is more than the acceptable limit. The white blood cell count increase is normal after birth, possibly a result of stress and tissue trauma during the birthing process.

The nurse is caring for a client during the early postpartum period. The client alerts the nurse that she is experiencing severe pain. The nurse interviews the client, obtains her vital signs, and performs a physical assessment. What does this assessment most likely reveal?

Vaginal hematoma Rationale: Theses are the classic signs and symptoms of a vaginal hematoma. The signs and symptoms do not indicate uterine or urinary infection; the temperature would be increased in the presence of infection. Postpartum hemorrhage would reveal persistent vaginal bleeding with a decreasing blood pressure

The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained?

checking the client's reflexes Rationale: The client is exhibiting signs of preeclampsia. The presence of hyperreflexia indicates central nervous system irritability, a sign of a worsening condition. Checking the client's reflexes will help direct the primary healthcare provider to appropriate interventions and alert the nurse to the possibility of seizures. Although the primary healthcare provider will be called, a complete assessment should be performed first to obtain the information needed. Determining the client's blood type is not necessary at this time; assessment of neurologic status is the priority. An IV may be started after the assessment; however, a more dilute saline solution will be prescribed.

A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one indication that the client should refrain from intercourse during pregnancy?

premature rupture of membranes Rationale: Ruptures membranes leave the products of conception exposed to bacterial invasion. Intact membranes act as a barrier against organisms that may cause an intrauterine infection. Fetal tachycardia may occur during sex, but there is no evidence that it is harmful for the fetus. Leukorrhea is common b/c of increased production of mucus containing exfoliated vaginal epithelial cells; intercourse is not contraindicated by leukorrhea. intercourse is not contraindicated near the estimated date of birth if the membranes are intact; modification of sexual positions may be needed b/c of the enlarged abdomen.

A client in labor is admitted with a suspected breech presentation. Which occurrence should the nurse be prepared for?

prolapsed cord Rationale: The feet/buttocks do not black the cervical opening effectively. The cord may slip through the cervix and become compressed. This is a life-threatening event for the fetus. Uterine inertia may result from fatigue or cephalopelvic disproportion; it is not related to fetal position. When a fetus is n the breech presentation the labor is usually long and difficult. Rapid dilation and precipitate labor may occur with fetuses in the cephalic position as well as the breech position.

A nurse is caring for four mother-baby couplets on the postpartum unit. Which new mother is at the greatest risk for postpartum hemorrhage?

A grand multipara who experienced a labor that lasted 1 hour Rationale: Increased parity contributes to an increased incidence of uterine atony because the uterine muscle may not contract effectively, leading to postpartum hemorrhage; it is not uncommon for a grand multipara to have labor that lasts 1 hour. A primipara should maintain a well-contracted uterus; with only one pregnancy, the uterus usually maintains its tone. Expulsion of the placenta 10 minutes after the birth of the fetus is expected and will not affect the tone of the uterus. Uterine atony is not a major problem associated with epidural anesthesia.

A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70mmHg, pulse of 90bpm, respiratory rate of 22 breaths/min, and fetal heart rate of 132 bpm. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect?

placenta previa Rationale: A contender uterus and bright-red bleeding are classic signs of placenta prevue; as the cervix dilates, the overlying placenta separates from the uterus and begins to bleed. There is no information to indicate that the client is in labor. There is no indication that the client was having contractions that have now ceased. The classic adaptations to abruptio placentae are pain and a rigid boardlike abdomen; dark-red blood may or may not be present.

Which client is at increased risk for postpartum hemorrhage?

one who gives birth to an infant weighing 9 lb 8 oz (4366 g) Rationale: The risk for postpartum hemorrhage is treated with large infants, b/c the uterine musculature has been stretched excessively, thus impairing the ability of the uterus to contract after the birth. Early breast-feeding stimulates uterine contractions and lessens the chance of hemorrhage. Having a pudendal block for the birth does not contribute to the risk for postpartum hemorrhage, b/c the anesthetic for a pudendal block does not affect uterine contractions. A third stage of labor lasting less than 10 minutes is a short 3rd stage; a prolonged 3rd stage of labor, 30 minutes or longer, could increase the risk of postpartum hemorrhage.

When assessing the neonate and mother after a vaginal delivery, the nurse finds that the neonate's blood group is B + and mother's is AB -. The nurse also finds that the mother has a negative Coombs test. What is the appropriate nursing intervention?

Administering Rho(D) immune globulin IM to the mother whiten 72 hrs of delivery Rationale: Rh sensitization occurs in an Rh - mother who has given birth to an Rh + neonate. Rh sensitization in the mother can result in erythroblastosis fettles during a second pregnancy. To reduce the risk of Rh sensitization, the Rh - mother should receive Rho(D) immune globulin IM within 72 hrs of delivery. IV infusion of this is usually reserved for emergency situations such as a threaded abortion.

Twenty-four hours after an uncomplicated labor and birth a client's complete blood count reveals a white blood cell (WBC) count of 17,000/mm3. How should the nurse interpret this WBC count?

An expected response to the process of labor and birth Rationale: During the postpartum period, leukocytosis (WBC count of 15,000 to 20,000/mm3) is expected and related to the physical exertion experienced during labor and birth. A count of 17,000/mm3does not constitute a drop in the WBC count, because the usual postpartum WBC count is between 15,000 and 20,000/mm3. WBC count normally increases after delivery. Because this is a normal response, it is not an indication of viral or bacterial infection.

A registered nurse teaches a nursing student about the effect of aspirin in pregnant women. Which statement made by the nursing student indicates a need for further teaching?

"Aspirin may cause Reye syndrome." Rationale: Aspirin does not cause Reye syndrome in pregnant clients. Aspirin may reduce fever, increase the risk of bleeding, and suppress labor contractions.

During her fist prenatal visit a client tells the nurse that she needed an exchange transfusion when she was born b/c of Rh incompatibility. She asks the nurse whether the baby will need one also. How should the nurse respond?

"You should have no problem, b/c you're Rh positive." Rationale: Rh incompatibility occurs if the mother is Rh negative and becomes sensitized and the infant is Rh positive. B/c the client had Rh incompatibility, she is Rh positive, and her infant will not be affected. There is no chance that the newborn will have Rh incompatibility.

A 37 y/o woman agrees to have a prenatal test done in order to diagnose fetal defects. There is a history of Down syndrome in her family. Which invasive prenatal test provides the earliest diagnosis and rapid test results?

Chorionic villus sampling Rationale: Chorionic villus sampling may be performed b/w 10-12 weeks.

What is the widely used off-label drug for cervical ripening and the enhancement of uterine muscle tone?

misoprostol Rationale: Misoprostol is the most widely used off-label drug for cervical ripening and the enhancement of uterine muscle tone b/c it is relatively affordable.

A primigravida in her first trimester visits the prenatal clinic for the first time. Which statement illustrates a psychologic reaction to pregnancy that usually occurs in the first trimester?

"I'm excited about the baby, but I'm not sure that I'm ready to be a mother." Rationale: The response "I'm excited about the baby, but I'm not sure that I'm ready to be a mother" reflects the ambivalence about the pregnancy that is typical during the first trimester. The statement "I know I'm going to be a terrible mother—I'll forget the baby when I go out" is a typical response during the third trimester, when the client begins to doubt her ability to be a good parent. Fantasizing about the infant, its sex, and its future is common during the second trimester. Expressing fears about the birthing process and parenting is common during the third trimester.

A nurse is caring for a postpartum client. Where does the nurse expect the fundus to be located if involution is progressing as expected 12 hours after the birth?

1 cm above the umbilicus Rationale: Twelve hours after birth, the uterus is 1 cm above the umbilicus, and each succeeding day it descends one fingerbreadth. Therefore the uterus should be 2 cm below the umbilicus on the second postpartum day. A uterus 3 cm above the umbilicus indicates that the bladder is full. The uterus is below the umbilicus on the fourth postpartum day because the uterus descends one fingerbreadth per day.

When does a nurse caring for a client with eclampsia determine that the risk for another seizure has decreased?

48 hours Rationale: The danger of a seizure in a woman with eclampsia subsides when postpartum diuresis has occurred, usually 48 hours after birth; however, the risk for seizures may remain for as long as 2 weeks after delivery. After birth occurs, after labor starts, and 24 hours after delivery are all too soon.

The nurse is assigned the care for an infant in the newborn nursery who is 24 hours old. During assessment the nurse becomes concerned that the baby is jaundiced. The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches what level?

5 to 7 mg/dL (85.5 to 119.7 mcmol/L)

The nurse is obtaining a health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. Which positive sign of pregnancy should the nurse evaluate in this client?

Audible fetal heartbeat Rationale: The presence of the fetal heartbeat is a positive sign of pregnancy. The feeling of movement is a presumptive sign of pregnancy. An enlarged abdomen is a probable sign of pregnancy. The bluish color of the cervix (Chadwick sign) is caused by pelvic congestion and edema; it is a probable sign of pregnancy.

A client who is at 20 weeks visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8 degrees F, pulse 80bpm, BP of 128/80mmHg, weight of 142 lbs (prepregnancy weight 132 lbs), FHR of 140 bpm, urine negative for protein, and fasting BG of 92. What should the nurse do after making these assessments?

Document the results b/c they are expected at 20 weeks

What is the desired outcome for the intrapartum client during the 3rd stage of labor?

Firmly contracted uterine fundus Rationale: The third stage of labor spans the time from the birth of the baby to the delivery of the placenta; a firmly contracted uterus is desired because it minimizes blood loss. Providing comfort is a desirable goal, but is secondary to the life-threatening possibility of hemorrhage associated with a boggy uterus. Efficient fetal heart beat-to-beat variability is a concern in the first and second stages of labor; it is no longer applicable after the fetus is born. The maternal respiratory rate may vary above or below this range.

A 29 week pregnant woman is found to have uterine contractions. Which medication does the primary healthcare provider prescribe?

Indomethacin Rationale: Substantial uterine contractions that occur prior to the 37th week of pregnancy should be stopped b/c a premature birth increases the risk of neonatal death. Therefore, indomethacin should be given for the management of preterm labor.

During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion?

Lethargy; ambivalence; emotional liability Rationale: Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, a person or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is also associated with postpartum depression

A nurse is caring for a preterm infant with necrotizing enterocolitis NEC. Which nursing intervention is most important for this infant?

Measuring abdominal girth frequently Rationale: NEC is marked by prolonged gastric emptying; an increase in abdominal girth of more than 1 cm in 4 hrs is significant and requires immediate intervention. Formula feeding is stopped and parenteral fluids, usually total parenteral nutrition TPN, are started instead. Administering oxygen before the gastric feeding will have no therapeutic value for an infant with NEC.

A client wants to abort her pregnancy after 4 months of gestation. Which oral medication would be given to the client?

Misoprostol Rationale: Misoprostol is an oral drug used to induce an abortion.

The triage nurse in the ED receives four clients simultaneously. Which of these clients should the nurse determine can be treated last?

Older adult male with a laceration to the finger Rationale: Although a client with a partially amputed finger needs control of bleeding, the injury is not life threatening and the client can wait for care. A woman in active labor should be assessed immediately, b/c birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.

A 38 y/o client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum Alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply?

Open neural tube defects Rationale: An increased level of alpha-fetoprotein (AFP), a fetal serum protein, has been found to reflect open neural tube defects such as spina bifida and anencephaly. Trisomy 21 is revealed by genetic testing of fetal cells. Genetic studies will reveal the presence of just one X chromosome in a female child. Genetic testing, not AFP testing, will reveal chromosomal aberrations.

A client at 38 weeks gestation is admitted for induction of labor. Her membranes ruptured 12 hours ago. There are not other signs of labor. Which medication does the nurse anticipate all be prescribed.

Oxytocin

The nurse teaches a client who is scheduled for an elective cesarean birth several exercises that may be performed on the first postoperative day. The nurse concludes that further teaching is necessary when the client states that one of the exercises is what?

Pelvic rocking Rationale: Pelvic rocking on the first postoperative day could be very painful and might traumatize the wound site. Leg bends promote circulation in the lower extremities and help alleviate gas pains. Foot circles promote circulation in the lower extremities. Shoulder circles relieve neck stiffness and tension that may be present in the postpartum period

The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk?

Perinatal mortality is two to three times more likely in multiple than in single births. Rationale: Perinatal morbidity rates are higher with multiple-gestation pregnancies, b/c the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk.

A nurse explains preterm labor to a group of nursing students. Which description of preterm labor indicates effective teaching?

Preterm labor is defined as contractions b/w 20 and 36 weeks of gestation. Rationale: Preterm labor involves uterine contractions that can proceed to delivery; these contractions occur b/w 20 and 36 weeks of gestation.

The parents of a newborn who is undergoing phototherapy ask the nurse why their baby's eyes are covered with eye patches. Which information is important for the nurse to remember before responding?

They prevent injury to the conjunctiva and retina. Rationale: Eye patches are applied while an infant is undergoing phototherapy to prevent drying of the conjunctiva, injury to the retina, and alterations in biorhythms. The infant will close the eyes automatically in response to bright lights and application of a patch. The infant should be exposed to bright lights periodically so circadian rhythms will become established. Rapid eye movements are automatic during different phases of sleep and will not be affected by the eye patches.

A nurse is giving discharge instructions to a new mother. What is the most important instruction to address the prevention of postpartum infection?

Wash your hands before and after changing your sanitary napkins Rationale:Infection is the most commonly transmitted through contaminated hands. Tub baths are permitted. Douching is contraindicated. Tampons are contraindicated in the postpartum period until the cervix has closed completely; they may promote infection when used too early.

Which drug is used to counteract drug toxicity caused by magnesium sulfate in preterm labor management?

calcium gluconate Rationale: Mag Sulfate is used to treat pregnancy-induced HTN. Calcium gluconate should be readily available to counter the drug toxicity caused.

A pregnant client at 30 weeks gestation begins to experience contractions every 5-7 minutes. She is admitted with a diagnosis of preterm labor. Although the client is being given tocolytic therapy, her cervix continues to dilate, and it is determined that a preterm birth is inevitable. Which medication does the nurse expect the primary HCP to prescribe?

dexamethasone Rationale: Dexamethasone is a glucocorticoid that stimulates the production of fetal lung surfactants, which are needed for fetal lung maturity; administration is started 48 hours before the expected birth.

A pregnant client has labor pains. However, the nurse finds that the client's cervix is not dilated. Which drug should be administered to the client to promote labor?

dinoprostone Rationale: Dinoprostone induces cervical ripening, which helps in the induction of labor at term.

A client at 35 weeks calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The most appropriate recommendation by the nurse is to have the client call the clinic with the results after she has done what?

drunk a glass of orange juice and timed 10 fetal movements Rationale: Drinking OJ can increase fetal movement. Fetal kick count, either the number counted in 30 minutes or the time it takes for 10 kicks to occur, is the accepted method of assessing the fetus for the appropriate amount of movement.

A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response?

extra circulating glucose causes the fetus to acquire fatty deposits Rationale: It is difficult to maintain maternal normoglycemia throughout pregnancy; excess glucose passes into the fetus, where it is converted to fat. The problem is excess glucose, which is why exogenous insulin must be administered. Although all pregnant women consume extra calories to meet the increased metabolism associated with pregnancy, fetal insulin does not pass from the fetus to the mother. Stating that fetal weight gain increases b/c pregnant women commonly overeat is a stereotypical statement; not all clients with diabetes overeat.

A client in her second trimester is at the prenatal clinic for a routine visit. While listening to the fetal heart, the nurse hears a heartbeat at the rate of 136 in the right upper quadrant and also at the midline below the umbilicus. What are the sources of the two sounds?

funic souffle and fetal heart rate Rationale: The funic souffle is the sound of blood rushing through the fetal umbilical cord and is therefore the same rate as the fetal heart rate. Twins will have different heart rates. The maternal heart rate should be much lower than the fetal heart rate. The uterine souffle, caused by blood moving through the maternal side of the placenta, is the same as the mother's heart rate, which should be less than 100.

A client who is at 12 weeks gestation tells the nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. Which factor is frequently associated with this disorder?

high level of chorionic gonadotropin Rationale: A high level of chorionic gonadotropin is frequently associated with severe vomiting during pregnancy and may result in hyperemesis gravidarum. A high level may also occur in the presence of a hydatidiform mole or multiple pregnancy. Cholecystitis is unrelated to this problem. Hydramnios (excessive amniotic fluid) is associated with multiple gestations and some fetal abnormalities. There are no data to indicate that there is decreased gastric acid secretion during the first trimester, and this is not the cause of hyperemesis gravidarum.

What tocolytic agent inhibits prostaglandin activity and is given along with sucralfate to help manage preterm labor?

indomethacin Rationale: Indomethacin is a NSAID that may cause gastric irritation so sucralfate is administered along with this drug.

A nurse who is caring for a mother and her newborn infant reviews their record. In light of the data the record contains, which nursing intervention is required? Maternal lab tests: Rh (-); Rubella titer 1:2; APR/VDAL Neg; HB Sag Neg; HIV Neg; Hbg/Hct 11/33; Sickle prep Neg Infant lab tests: BG 46; Bili 10mg; Blood O-; Hct 55

maternal rubella vaccination Rationale: A rubella titer of 1:2 is inadequate immunization. A titer of 1:8 is considered adequate immunity. Rubella immunization protects the fetuses of future pregnancies from significant birth defects caused by a rubella infection.

A post-dated pregnant client is admitted to the hospital for labor induction. Which medication would the primary HCP prescribe?

oxytocin

A nurse is caring for a pregnant woman in active labor who is lying in bed in the high fowler position. Epidural anesthesia and an oxytocin infusion were started 45 minutes ago. The client complains of feeling lightheaded and nauseated. What should the nurse do first after reviewing the client's admission data, vital signs, and current status?

place the client in a 15 degree side lying position Rationale: The client's BP has decreased, causing supine hypotension. The side-lying position promotes placental perfusion. The contractions and fetal heart rates are within the expected range.

A client at 38 weeks is admitted to the high-risk prenatal unit with a diagnosis of severe preeclampsia. The nurse obtains the vital signs, performs a health history and physical assessment, and reviews the client's laboratory results. What is the priority nursing intervention at this time?

providing a dark room Rationale: Increasing cerebral edema may predispose the client to seizures; therefore, stimuli of any kind should be minimized. Although intake and output should be monitored to identify oliguria, this will not limit the occurrence of a seizure. A cesarean birth may not be necessary.

While receiving betamimetic (tocolytic) therapy for preterm labor the client begins to experience muscle tremors and exhibit signs of nervousness. She reports, "My heart is racing." The nurse identifies that the client's pulse rate is 110bpm and regular. What should the nurse do next?

reassure the client that these are expected side effects of the medication Rationale: Betamimetics have the unpleasant side effects of nervousness, tremors, and palpitations; clients should be informed that these side effects are expected.

When a preterm newborn requires O2, the nurse in the NICU monitors and adjusts the O2 concentration. Which complication do these adjustments attempt to prevent?

retinopathy of prematurity Rationale: Retinopathy of prematurity is caused by the high concentration of O2 that may have to be used to support some preterm neonates; O2 must be administer cautiously and, depending on the neonate's blood O2 level, adjusted accordingly. Cataracts and strabismus are not caused by a high O2 concentration. Ophthalmia neonatorum refers to an inflammation of the eyes caused by gonorrheal or chlamydial infection contracted as the fetus passes through the birth canal.

A client who is 28 weeks into her second pregnancy is experiencing increased edema in the lower extremities. The nurse advises rest with the legs elevated and provides dietary instructions. What other advice should the nurse provide?

the selected foods do not need to have low salt content Rationale: Dependent edema is common during the last trimester; there is no need to lower the salt content of the client's diet. Teaching should be based on optimal nutrition, as well as the caloric content of the diet. Not all preferences can be included; the diet should include a normal sodium and high protein intake and sufficient calories. Immediate planing based on the nurse's knowledge of dietary needs is sufficient. Unless there is reason to believe that a needs for medical intervention exists, the nurse may discuss care related to human responses.

Immediately after the third stage of labor a nurse administers the prescribed oxytocin infusion. Why is this medication administered?

to help the uterus contract Rationale: Oxytocin given after the third stage of labor will stimulate the uterus to contract and remain contracted.

What drugs are used to induce abortion in an adolescent?

- misoprostol - mifepristone - methotrexate Rationale: Misoprostol is a prostaglandin analog that acts directly on the cervix, stimulating contractions. Mifepristone acts by binding to progesterone receptors and blocking the action of progesterone, which is necessary for maintaining pregnancy. Methotrexate is a cytotoxic drug that can cause early abortion by blocking folic acid in fetal cells.

A new mother wishes to breast-feed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond?

"You'll need greater amounts of the same food you've been eating and more fluids." Rationale: Compared with the prenatal diet, the diet for location requires an increased intake of all food groups, vitamins, and minerals, plus increased fluid ro replace that lost with milk secretion. Great-feeding mothers need an additional 340 calories and 25 g of protein per day more than nonpregnant needs to maintain adequate milk production. The client needs additional calories, not just additional milk. Telling the client that her body produces the milk her baby needs as a result of the vigorous suckling does not address the mother's concern; optimal nutrition is necessary to produce an adequate milk supply.

What is a priority interventions for the infant undergoing phototherapy?

Exposing as must skin as possible by turning the infant every 2 hours Rationale: Turning the infant permits optimal skin exposure to the phototherapy lights. The infant's face should not be covered; only the eye should be covered. Glucose water does not promote exertion of bilirubin in the stool. The supine position would only expose the front of the infant to the lights.

Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her primary HCP. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action?

Give the infant to the client and instruct her regarding the infant's care. Rationale: When a client signs herself and her infant out of the hospital, she is legally responsible for her infant. The infant is the responsibility of the mother and can leave with the mother when she signs them out.

Shortly after giving birth, a client says she feels as though she is bleeding excessively. When checking the fundus, a nurse observes a steady trickle of blood from the vagina. What is the nurse's initial action.

Holding the fundus firmly and gently massaging it Rationale: A relaxed uterus is the most common cause of bleeding in the early postpartum period. The uterus may be returned to a state of firmness with the use of intermittent gentle fundal massage. Immediate action is directed toward the client's safety; the primary healthcare provider is called if nursing intervention does not control the bleeding. The vital signs are checked after another intervention that addresses the client's immediate needs. Steady bleeding is a complication that must be attended to immediately.

A client measuring at 18 weeks' gestation visits the prenatal clinic stating that she is still very nauseated and vomits frequently. Physical examination reveals a brown vaginal discharge and a blood pressure of 148/90 mm Hg. What condition does the nurse suspect the client is experiencing?

Hydatidiform mole Rationale: A hydatidiform mole, in which chorionic villi degenerate into grape like vesicles, is most often the cause of the S&Ss. Although vomiting may cause dehydration, this conclusion ignores the vaginal discharge and HTN.

A woman comes into the clinic and states that she is thinking about becoming pregnant. What can the woman do to improve the health of her baby before she becomes pregnant?

Start taking prenatal vitamins Rationale: Folic acid is important for the pregnant woman; a lack of folic acid can result in neural tube defects, including spina bifida. The time during fetal development when this occurs is very early in the pregnancy, when the woman may not even realize she is pregnant. Taking prenatal vitamins with adequate folic acid can greatly reduce this birth defect. Although exercise is good for the pregnant woman and infant, it is not necessary to start running 3 miles a day, especially if this is something the client has never done before. Running may not be healthy for the soon-to-be mother and infant if it is a new activity; however, if this is what the woman normally does, she will be encouraged to continue.

Which interventions would reduce the risk of perinatal transmission via vaginal birth in an adolescent who is diagnosed with HIV infection?

Using antiretroviral during the intrapartum period Rationale: In the intrapartum period, antiretroviral therapy is recommended to prevent transmission of HIV. Therefore the risk of perinatal transmission may be reduced in an adolescent who received antiretroviral therapy in the intrapartum period.

The nurse is reviewing the obstetric history of a client who has had an abruptio placentae. Which prenatal condition does the nurse expect to find in this client's history?

gestational HTN Rationale: HTN during pregnancy leads to vasospasm; this in turn cause the placenta to tear away from the uterine wall.

A client with poorly controlled type 1 DM is not in her 34th week of pregnancy. The primary HCP tells her that she should have an amniocentesis at 37 weeks to assess fetal lung maturity and that induction of labor will be initiated if the fetus's lungs are mature. The client asks the nurse why an early birth may be necessary. How should the nurse reply?

"Your glucose level will be hard to control as you reach term." Rationale: Explaining the risk to the fetus increases as the pregnancy reaches term secondary to the mother's poorly controlled DM provided accurate information and answered the client's direct question. Labor is never induced for the sole purpose of preventing preeclampsia. This is not the reason for early induction; the longer the pregnancy is allowed to progress, the greater the risk for complications or a stillbirth; if the fetus becomes compromised, an emergency c-section is usually required. Neonates can develop hypoglycemia shortly after birth related to many factors such as GDM and hypothermia, but this is not related to an early birth. The infant's size is anticipated to be larger than normal, not smaller.

A pregnant woman at 6 weeks gestation tells the nurse at her first prenatal visit that she uses an OTC herbal product as a health supplement. What should the nurse recommend to this client?

- Stop taking the supplement immediately -Discuss the use of the supplement with the practitioner -Discuss the use of any over-the-counter products with the practitioner. Rationale: Stopping the supplement is appropriate until more instructions are received from the practitioner. It is the practitioner's responsibility to counsel the client regarding all prescriptions, over-the-counter medications, and supplements. Continuing or increasing the dose of the supplement is unsafe; it may be detrimental to both the client and the fetus. The nurse may not prescribe medications of any kind, and to do so is functioning outside of the legal definition of nursing practice. It is the practitioner's responsibility, not the pharmacist's, to counsel the client regarding all prescriptions, over-the-counter medications, and supplements.

The nurse is assessing a female preterm neonate after delivery. Which assessment findings does the nurse document in the hospital reports fo the infant?

- The infant has a prominent clitoris. - The hair of the infant is fine and feathery. -The infant shows no resistance to the heel-to-ear maneuver. Rationale: A female preterm neonate lacks proper growth fo the labia major; therefore, the neonate will have a prominent clitoris. A preterm neonate lacks proper nourishment to the hair, resulting in fine and feathery hair. The knee of an preterm infant does not offer resistance to the heel-to-ear maneuver. The soles of a preterm infant's feet appear more turgid and may have only fine wrinkles. The preterm infant has less subcutaneous tissue, and therefore rests in a relaxed attitude.

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? SATA

- Wash your hands before touching the newborn - all client identification bands should remain in place until discharge -check the identification of staff, and if there is a question of validity, call the nursing station Rationale: Mothers, significant others or persons of the mother's choice, and the infant must continue to wear identification bands during the entire hospital stay. These bands must continue to wear identification bands during the entire hospital stay. These bands show which baby belongs to which mother. The mother should call the nursing station to verify any person appearing to be staff if she has any question about who the person is. Proper identification must be worn by staff at all times. Washing hands before touching the newborn will decrease the chance of infectious transfer of microorganisms to newborn. Safety is the most important concern. There may be times when procedures, assessments, showering, and other activities involve the newborn being taken from the mother's room. Only well-identified staff members caring for the client should be allowed to take the infant out of the mother's sight. It is not necessary to send the newborn to the nursery during the night; the mother may keep the baby at her side during this time.

A primigravida client with type 1 diabetes is attending her first prenatal visit. While discussing changes in insulin needs during pregnancy and after birth, the nurse explains that in light of the client's blood glucose readings, she should expect to increase her insulin dosage. B/w which weeks of gestation is this expected to occur?

24th and 28th weeks of gestation Rationale: At the end of the second trimester and the beginning of the third trimester, insulin needs increase because of an increase in maternal resistance to insulin. During the earlier part of pregnancy, fetal demands for maternal glucose may cause a tendency toward hypoglycemia. During the last weeks of pregnancy, maternal resistance to insulin decreases and insulin needs decrease accordingly.

What is the drug of choice for a client who wants to abort her pregnancy at three months of gestation?

mifepristone Rationale: Mifepristone is a progesterone antagonist that stimulates uterine contractions; it is used to selectively terminate a pregnancy.

A client comes to the clinic for a 6-week postpartum check-up. She confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant "cries all of the time." When asked whether she has a support system, she replies that she lives alone. Which response would provide the most accurate information?

Asking the client questions, using a postpartum depression scale Rationale: A postpartum depression scale is a validated tool for identifying women who might be experiencing postpartum depression. The most widely used and validated tools are the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale. Although providing community resources of a local support group may be helpful, it is not useful in assessing the client's current emotional status. Although postpartum blues caused by hormonal changes soon after pregnancy might be common, feelings of depression and fatigue 6 weeks after childbirth is a matter of concern. The client may not have anyone else who can provide child care, or the client may not follow through on the recommendation. In addition, this intervention does not provide any information on the client's current emotional status.

A client at 30 weeks is admitted to the hospital with a diagnosis of a low-lying placenta previa with slight vaginal bleeding. The client is stabilized and bleeding ceases. What is the nurse's primary focus when providing discharge teaching about care at home for this client?

Avoid situations that may stimulate the cervix or uterus Rationale: Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided. A calm, quiet environment is desired for all clients, not just those with placenta previa. Fetal status is assessed during prenatal visits, which generally are scheduled twice a week. Ultrasonographic examinations may be performed every two weeks, and fetal surveillance, including biophysical profiles and non stress testing, are done during twice-weekly visits. If bleeding is under control and the client is stable, bathroom privileges and sitting in a chair for about an hour daily are allowed.

An infant is admitted to the nursery after a difficult shoulder dystocia vaginal birth. Which condition should the nurse carefully assess this newborn for?

Brachial plexus injury Rationale: Brachial plexus paralysis (Erb palsy) is the most common injury associated with disytocia related to a shoulder presentation; it is. caused by pressure and traction on the brachial plexus during the birth process. The newborn's face is not involved with a shoulder presentation. Cephalhematoma is a soft-tissue injury of the head and is not related to shoulder dystocia. Spinal cord syndrome is associated with a breech presentation and is not related to shoulder dystocia.

A client at 35 weeks who has had no prenatal care arrives in labor and delivery and is found to be 20% effaced and 2cm dilated. Her membranes are intact and contraindications are 3 mins apart. The nurse notices some ruptures blister like vesicles in the genital area. What should the nurse's next action be?

Contacting the HCP regarding the needs for a cesarean birth Rationale: Transmission of genital herpes simplex virus to the newborn can occur during vaginal delivery when active lesions are present. Blindness, brain damage, or death could result if early measures are not taken. The priority is informing the primary HCP of the presence of active genital herpes lesions so preparations for a cesarean birth may be made. The nurse would not want to enhance contractions; instead the nurse will begin preparations for a cesarean birth ASAP.

A client has been taking methadone 40 mg/day for treatment fo an opioid addiction. During a methadone clinic visit she tells the counselor that she is 3 months pregnant and receiving prenatal care. The counselor notifies the nurse in the prenatal clinic about the client's addiction history. What should the nurse in the prenatal clinic recommend that the client do?

Continue the prescribed methadone to prevent withdrawal symptoms. Rationale: Methadone is the only medication approved for the treatment of pregnant women with opioid addiction. Although methadone crosses the placenta, it is considered safe for the newborn than an acute opioid detoxification that would result if the methadone was not administered. Withdrawing the methadone slowly over the nest several weeks is not recommended. Detoxification from methadone, a long-acting opioid, takes longer than several weeks. Discontinuing methadone treatment can lead to withdrawal problems and put the client at risk for a return to opiod abuse. If methadone is discontinued during pregnancy, birth client and fetus will be at risks. i

During the 4th stage of labor, about 1 hour after giving birth, a client begins to shiver uncontrollably. What should the nurse's priority intervention be?

Cover the client with blankets to alleviate this typical postpartum sensation. Rationale: There are several theories about why chilling occurs; one is that it is caused by vasomotor instability resulting from fetus-to-mother transfusion during placental separation; comfort measures such as warm blankets or fluids are indicated. Although the vital signs should be monitored during the fourth stage of labor, they are not being monitored because of the shivering, which is an expected response to the birth. Changes in blood pressure are unexpected. Shivering is not a sign of dehydration.

Twelve hours after a spontaneous birth a client's temperature is 100.4 F (38 C). What should the nurse suspect as the cause of this increase in temperature?

Dehydration Rationale: A client's temperature may increase to 100.4 F (38 C) during the first 24 postpartum hours as a result of dehydration and expenditure of energy during labor. Mastitis may develop after breastfeeding has been established and mature milk is present. A puerperal infection usually begins with a fever of 100.4 F (38 C) or more on 2 successive days, excluding the first 24 postpartum hours. Urinary tract infections usually become evident later in the postpartum period.

During the initial prenatal visit of a woman at 23 weeks, the nurse discovers that she has a history of pica. What is the most appropriate nursing action?

Determining whether the diet is nutritionally adequate Rationale: Pica is characterized by having an appetite for non-nutritive substances such as ice. The primary concern for pregnant women with pica is that the diet may be nutritionally inadequate. Nutritional guidance may be necessary, depending on the findings of this assessment. Pica does not necessarily indicate a psychologic disturbance although sometimes it can. Frequently, the client's culture promotes pica. If a substance is nontoxic to the mother, it is generally not fetotoxic either. Although iron is routinely prescribed during pregnancy, it does not specifically address the prectice of pica. The nurse needs to assess this client first to see fi she is currently practicing pica and, if so, evaluated its purpose for this client.

Which complication is a primipara with a second-degree laceration and repair most likely to experience during the postpartum period?

Difficulty voiding spontaneously Rationale: Voiding will be difficult because of periurethral edema and discomfort. Posterior vaginal varicosities rarely occur in primiparas, even when they are pushing during a prolonged second stage of labor. A second-degree laceration is unrelated to lactation. A second-degree tear is unrelated to bonding and attachment.

On the third postpartum day after a cesarean birth a client tells the nurse that her breasts feel warm, firm, and tender. The skin is shiny and taut. What does the nurse suspect as the cause of the client's breast discomfort?

Extended vascular and lymphatic circulation in the breasts Rationale: Increased circulation in the breasts cause engorgement, which immediately precedes milk production on the third to fifth postpartum day. Milk production has not yet begun; this engorgement, which precedes milk production. Acinar cells do no become overdistended because of the supply-and-demand nature of milk production; in addition, milk production is not yet established. Inadequate release of milk is impossible because the breasts have not yet filled with milk; engorgement is occurring.

A non stress test NST is scheduled for a client with preeclampsia. During the NST the nurse concludes that if accelerations of the fetal heart rate occur with fetal movement, this probably indicates what?

Fetal well-being Rationale: Accelerations of the fetal heart rate with fetal movement indicate fetal well-being. Early decelerations = head compression. Late decelerations = uteroplacental insufficiency. Variable decelerations = cord compression.

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)?

Gravida 1 who has had an intrauterine fetal death Rationale: Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk facts for DIC.

The nurse is teaching a prenatal and relaxation class. What intervention does the nurse suggest to ease back discomfort during labor?

Having support persons use back massage techniques Rationale: The fetus exerts pressure against the spine during labor; back massage provides counterpressure, which eases the discomfort. The back-lying position is contraindicated because the weight of the fetus compresses the vena cava, decreasing the flow of blood to the placenta. Although abdominal effleurage can serve as a distraction during labor, it will not relieve back discomfort. The knee-chest position will not relieve back pain during labor.

A nurse assesses a primigravida who has been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 secs and are 3-5 minutes apart. An oxytocin infusion is prescribed. What is the priority nursing intervention at this time?

Infusing oxytocin by piggybacking into the primary line Rationale: Piggybacking the oxytocin (Pitocin) infusion allows it to be discontinued, if necessary, while permitting the vein to remain open by way of the primary IV. Cervical dilation is checked when there is believed to be a change, not on a regular basis. Unless specifically requested by the client, there is no reason to maintain a dark, quiet labor environment. Although positioning the client on her left side is recommended, it is not the primary concern at this time; there are no data to indicate maternal hypotension.

A 30 week pregnant woman reports low backache and abdominal cramps. Which drug may prescribed if the client is suspected of having preterm labor?

Magnesium sulfate Rationale: Low backache and abdominal cramps in a pregnant woman may indicate labor; however, labor pains may not be she if the gestation is not full term. Magnesium sulfate may be prescribed to prevent preterm labor.

A client who has missed two menstrual periods tells a nurse at the prenatal clinic that a home pregnancy test was positive. Her last menstual period began on June 18. According to Nagele's rule, what is the estimated date of birth?

March 25 Rationale: Subtract 3 months; Add 7 days; Add 1 yr

The practice of separating parents from their newborn immediately after birth and limiting their time with the infants during the first few days after delivery contradicts studies related to what?

Parent-child attachment Rationale: There is a sensitive period in the first minutes or hours after birth during which it is important for later interpersonal development that the parents have close contact with their newborn. Rooming-in may not be instituted immediately after birth. Taking-in is a maternal psychologic behavior described by Reva Rubin that occurs during the first 2 postpartum days. Taking-hold is a maternal psychologic behavior described by Rubin that occurs after the third postpartum day.

The nurse is assessing several postpartum clients at the very beginning of her shift. Which problem does the nurse identify that might predispose a client to postpartum hemorrhage?

Multifetal pregnancy Rationale: The presence of more than one fetus overdistends the uterus, which may result in uterine atony and this postpartum hemorrhage. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage.

An infant in the nursery has cyanosis of the hands and feet and circumoral pallor when crying. In light of these assessment findings, which action should the nurse consider taking next?

Notifying the HCP, b/c circumoral pallor may signal a cardiac problem. Rationale: Cardiac pathology can be detected at an early age, and circumoral pallor may be a sign. Circumoral pallor is not expected in a healthy newborn, or in a person of any age.

Before discharge, what suggestion should the nurse give to a nonnursing mother to help limit breast engorgement?

Place raw cabbage leaves over the breast Rationale: Fresh, raw cabbage leaves placed over the breasts between feedings can help relieve engorgement. It is thought that the effect of the cabbage leaves is related to the coolness of the leaves and the presence of phytoestrogens. Engorgement last about 3 to 5 days. Milk and fluids should not be restricted during the postpartum period. Medications will ease pain; however, it will not limit further engorgement. Cold compresses will limit further engorgement in the nonnursing mother. Large bags of frozen peas make easy ice packs.

What nursing action is the priority for a client in the second stage of labor?

Promote effective pushing by the client Rationale: Effective pushing will hasten the passage of the fetus's presenting part through the birth canal. The fetal position is established before the second stage. Birth is imminent, and medication given at this time will express the newborn's respirations. Although the mother may breastfeed after the birth, during the second stage of labor she should be concentrating the birth process, not feeding the infant.

The nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first?

Reposition her on her left side. Rationale: Late decelerations may indicate impaired placental profusion. Turning the client on her left side relieves pressure on the vena cava and aorta, improving circulation to the placenta. Calling the practitioner is premature. The nurse should notify the practitioner if late decelerations continue after nursing interventions are implemented. Elevating the head of the bed will increase pressure on the vena cava and aorta, further reducing placental perfusion. Oxygen may be administered if placing the client on her left side does not resolve the late decelerations.

After an unexpected emergency cesarean birth the client tells the nurse. "I failed natural childbirth." Which postpartum phase adjustment does this statement most closely typify?

Taking-in Rationale: By discussing her birth experience, the client is bringing it into reality; this is characteristic of the taking-in phase. The client is not ready to assume the tasks of the letting-go phase until completing the tasks of the taking-in and taking-hold phases. The taking-hold phase is marked by an increased desire to resume independence; this statement reveals that the client is not ready for this phase. The working-through phase is not a separate phase of adjustment to parenthood; it is not relevant.

A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours after delivery. How does the nurse determine that the uterus is demonstrating appropriate involution?

The amount of lochia rubra is moderate Rationale: Red, distinctly blood-tinged vaginal flow (lochia rubra) is expected during the first few postpartum days and indicates that involution is progressing as it should. Clots indicate uterine atony, which prevents involution of the uterus. The status of the episiotomy is unrelated to the status of the uterus. Uterine cramps during breastfeeding are evidence that the uterus is undergoing appropriate involution

The nurse reviews the history of a neonate admitted to the nursery and discovers that the infant's mother was listed as Gravida 1 Para 1 before the baby was born. How should the nurse utilize these data in order to gather more information?

To consider that someone recorded the gravid and para incorrectly. Rationale: Gravida refers to pregnancies, including this one, and para refers to pregnancies terminated (by whatever means) after the age of viability. If this is the client's only pregnancy (gravida 1), she could not have had a previous pregnancy that ended after the age of fetal viability.

A newborn is being treated with phototherapy for hyperbilirubinemia. What is the nurse's role when providing phototherapy?

Turning the infant every 2 hrs Rationale: The infant's position is changed every 2 hours to expose all skin surfaces to the phototherapy for maximum effect. Measuring the bilirubin level every 2 hours is not necessary. The infant may be removed from the lights for feeding and the eye patches removed to assess the eyes for irritation. The lights will dry the cord more quickly, which is a desirable effect.

Why should the nurse limit food and oral fluids as a laboring client approaches the second stage of labor?

Undigested food and fluid may cause N/V and limit the choice of anesthesia. Rationale: Gastric peristalsis often ceases during periods of stress. Abdominal contractions put pressure on the stomach and can cause N/V, increasing the risk for aspiration. Although it is true that the increased acid secretion during the gastric phase may cause dyspepsia, it is not the reason for withholding food and oral fluids during labor; the primary reason for withholding it is the prevention of aspiration. Gastric peristalsis is decreased, not increased, during labor and birth.

What is the nurse's most critical assessment for a client with preeclampsia during the immediate postpartum period?

Vital signs Rationale: Clients with preeclampsia are at risk for a compromised cardiovascular and renal function and are still at risk for seizures in the immediate postpartum period; frequent assessment is vital in the first 48 hours. Although it is an integral part of care, evaluating the client's emotional status is not the priority. This client is at no higher risk for hemorrhage than any other postpartum client. Monitoring the client for hypovolemic shock is not the priority assessment at this time.

A client at 31 weeks' gestation is admitted in preterm labor. What class of drugs might the nurse anticipate being prescribed?

a beta-adrenergic Rationale: Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily. Other tocolytics that may be used are magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers.

A primipara gives birth to an infant weighing 9 lb 15 oz (4508 g). During labor a midline episiotomy is performed and the client sustains a 3rd degree laceration. The client tells the nurse that her perineal area is very painful. What is the physiological finding that is the cause of this pain?

A 3rd degree laceration extends through the perineal muscles and continues through the anal sphincter muscle. Cutting of the perineal muscles constitutes a 2nd degree laceration. Trauma to the rectum constitutes a a 4th degree laceration. Damage to superficial muscles is a 1st degree laceration.

A nurse is checking the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression?

Abrupt decreases in fetal HR that are unrelated to the contractions Rationale: Abrupt decreases in FHR that are unrelated to the contractions are variable decels that indicated cord compression. These are the most common during the 2nd stage of labor and are considered benign unless the HR does not recover adequately. A baseline reading indicates decreased variability and may have many causes, but it is not related to cord compression. FHR accelerations are not related to cord compression. Decels when a contraction begins that return to baseline when the contraction ends indicate head compression during contractions; they are an expected, benign finding.

After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include?

Administering additional fluids every 2 hours Rationale: Insensible and intestinal fluid losses are increased during phototherapy; extra fluid prevents dehydration. Taking the vital signs every hour is unnecessary unless a change from the baseline occurs. The eye shields should be removed for feeding and when the infant is being held. Some methods of phototherapy no longer require the use of eye shields. The total body needs to be exposed to the light.

A client at 24 weeks' gestation is admitted in early labor. What should the nurse take into consideration regarding this client's early gestation?

Birth at this gestational age usually results in a severely compromised neonate Rationale: Mobidity and mortality rates among preterm neonates are highest b/w 24-26 weeks' GA; complications include immature lung tissue, altered cardiac output, patent ductus arterioles, intraventricular hemorrhages, necrotizing enterocolitis, and infection. Depending on the status of cervical effacement and dilation the decision may be made to try halting labor with the use of tocolytic medications and limited activity. If possible, the pregnancy should be maintained past 37 weeks' gestation. Neonates born before 34 weeks are still at high risk.

A nurse is caring for a 6 day old preterm infant in the NICU. What complications should the nurse be alert for in this infant?

Necrotizing enterocolitis Rationale: NEC is an inflammatory disease of the GI mucosa that is related to several factors (e.g., prematurity, hypoxemia, high-solute feedings); it involves shunting of blood from the GI tract, decreased secretion of mucus, greater permeability, of the mucosa, and increased growth of gas-forming bacteria, eventually resulting in obstruction. NEC usually manifests 4-10 days after birth. Meconium ileum occurs within the first 24 hours when the newborn cannot pass any stool. It is not related to the development of NEC; it is a complication of cystic fibrosis. Duodenal atresia is a congenital defect that occurs early in gestation and is present at birth. Imperforate anus is an anorectal malformation that results in the absence of external anal opening; it is present at birth.

What is the priority nursing intervention for a laboring client with a sudden prolapse of the umbilical cord procuring from the vagina?

Preparing the client for surgery Rationale: The fetus's life is in jeopardy and a cesarean birth must be performed immediately. The cord is never handled because it may go into spasm and block the fetal blood supply. Neither checking the fetal heart rate every 15 minutes nor starting oxygen at 10 L/min with a tight face mask is the priority; the client must be prepared for an emergency cesarean birth.

A husband who is coaching his wife during labor demonstrates an understanding of the transition phase of labor when, as his wife starts to push with each contraction, he instructs her to do what?

Take quick, shallow breaths, and then blow Rationale: Taking quick, shallow breaths and then blowing helps to prevent pushing when full dilation has not yet occurred. Taking cleansing breaths isn to done until full dilation has occurred, b/c it can cause cervical edema and may tire the mother. Slow, rhythmic diaphragmatic breathing is don't early in the first stage of labor; it is ineffective in the transition phase. Switching b/w accelerated and decelerated is done in the middle of the first stage of labor.

Phototherapy is prescribed for preterm neonates with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy?

Using shields on the eyes to protect them from the light Rationale: The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant'a entire skin surge is exposed to the light. Vitamin E oil massage is contraindicated, b/c it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed.

The nurse is admitting a pregnant client who has mitral valve stenosis to the high-risk unit. Which prophylactic medication does the nurse anticipate administering during the intrapartum period?

antibiotic Rationale: Clients who have mitral valve stenosis are administered prophylactic antibiotic therapy to minimize the development of streptococcal infections that may cause endocarditis. A diuretic will probably be used if heart failure develops. A cardiotonic will probably be used if heart failure develops. An anticoagulant will probably be used if thrombophlebitis or atrial fibrillation develops.

A nurse is teaching a prenatal class regarding the physiologic alterations that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include?

- cardiac output increases - blood pressure decreases - the heart is displaced upward Rationale: Cardiac output increases during the second trimester due to an increasing plasma volume. The blood pressure decreases because of the enlarged intravascular compartment and hormonal effects on peripheral resistance. As the fetus grows and the enlarging uterus outgrows the pelvic cavity, it displaces the heart upward and to the left. The blood volume starts to increase earlier, but does not peak until the third trimester. The reduction in hematocrit occurs in the first trimester; the erythrocyte increase may not be in direct proportion to the blood volume, lowering hematocrit and hemoglobin levels, which remain lower throughout pregnancy.

A client with mild preeclampsia is admitted to the high-risk prenatal unit b/c of a progressive increase in her blood pressure. The nurse reviews the primary HCP's prescriptions. Which prescriptions does the nurse expect to receive for this client?

- daily weight - side lying bed rest - deep tendon reflexes Rationale: Rapid weight gain is a sign of increasing edema. One liter of fluid is equal to 2.2 lb. Maintaining bedrest promotes fluid shift from the interstitial spaces to the intravascular space, which enhances blood flow to the kidneys and uterus; the side-lying position promotes placental perfusion. A 2 g/day sodium diet will deplete the circulating blood volume, limiting blood flow to the placenta. A moderate sodium intake (≤6 g) is permitted as long as the client is alert and has no nausea or indication of an impending seizure. Deep tendon reflexes should be monitored. Reflexes of +2 are indicative of mild preeclampsia; +4 indicates severe preeclampsia. There is no data indicating that a glucose tolerance test is needed.

An epidural anesthetic is planned for the adolescent who is in labor. What nursing interventions are essential before epidural anesthesia is administered?

- performing a baseline vaginal examination - telling the adolescent what to expect with each procedure - identifying risk factors that contraindicate epidural anesthesia Rationale: A baseline vaginal examination is needed to determine the extent of cervical dilation and effacement. Before any procedure is implemented, the nurse should explain the procedure and answer any questions. Rick factors that contraindicate epidural anesthesia include antepartum hemorrhage, bleeding disorders, and allergy to the medication. None of these conditions is indicated in the client's history.

What complications are associated with excessive weight gain during pregnancy in adolescents?

- preterm labor - cesarean delivery - postpartum obesity Rationale: Excessive weight gain during pregnancy is associated with such complications of labor and delivery as preterm labor and cesarean delivery. It is also linked with postpartum obesity and its associated health risks.

A woman visits the prenatal clinic b/c of an OTC pregnancy test has rendered a positive results. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. What should the nurse include?

- sleep needs increase - urinary frequency - calcium requirements remain the same Rationale: Estrogen increases the secretion of corticosteroids, which decrease the basal metabolic rate, resulting in fatigue. Sodium is retained. Urinary frequency occurs. During the first trimester approximately 1000 mg of calcium is needed each day. There is no longer a recommendation for an increase in daily calcium intake for 1000mg for women older than 19 and 1300mg for women younger than 19 is adequate for fetal bone and tooth development. Body temperature increases because of the increased metabolism related to the growth of the fetus. Carbohydrate needs increase because the secretion of insulin by the pancreas is increased; however, insulin is destroyed rapidly by the placenta. The stress of pregnancy may precipitate gestational diabetes.

Oxytocin is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 secs or longer occur?

- stopping the infusion - turning the client on her side - notifying the primary HCP - verifying the duration of contractions Rationale: Discontinuing the oxytocin infusion decreases uterine stimulation and eases intrauterine pressure; continuing the oxytocin may lead to fetal hypoxia, placental separation, or uterine rupture. Turning the client on her side increases oxygen perfusion to the fetus. The primary healthcare provider should be notified to obtain additional prescriptions. Contractions lasting longer than 90 seconds warrant stopping the oxytocin infusion to prevent uterine rupture. Magnesium sulfate is prescribed for preterm labor to inhibit contractions; this client needs to continue with labor. The goal is to decrease the length of contractions, not to stop them.

A nurse is administering 5,000 units of heparin to a prenatal client on prolonged bed rest. The label indicated that there are 20,000 units of heparin in each mL of solution. How much solution should the nurse give the client?

0.25 mL

A nurse is teaching a young primigravida regarding expected body changes during pregnancy. The nurse explains that most prenatal clients experience urinary frequency in the first trimester due to an increase in what?

Bladder pressure from an enlarged uterus Rationale: The anatomic position of the uterus in the pelvis is directly above the urinary bladder; as the uterus enlarges, it exerts pressure on the bladder. After the first trimester the uterus rises into the abdominal cavity and urinary frequency lessens. Estrogen causes fluid retention, not frequency. An increase in extracellular fluid does not occur until the second trimester. An increased glomerular filtration rate does not cause urinary frequency.

A nurse is caring for a primigravida during labor. At 7 cm of dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?

Butorphanol Rationale: Respiratory depression may occur in the newborn because the duration of action of butorphanol is 3 to 4 hours and the circulating blood level will be high if birth occurs during that time. Hydroxyzine, promethazine, and diphenhydramine are all antihistamines that have a sedative effect and are administered early in labor to promote sleep and decrease anxiety.

What is the first line of drug used to manage intrauterine fetal death?

Dinoprostone Rationale: Dinoprostone (Cervidil) is a synthetic derivative of the hormone prostaglandin E2, which is used to induce labor after establishing intrauterine fetal demise of up to 28 weeks of gestational age. Misoprostol (Cytotec) is a synthetic prostaglandin E1 analog typically used as an antiulcer agent that also has an off-label use for cervical ripening (softening), and it is used in combination with mifepristone (RU486) to induce abortion. Methylergonovine maleate (Methergine) is an ergot derivative that functions as an oxytocic and is prescribed to reduce postpartum hemorrhage when uterine massage does not improve uterine tone to decrease bleeding.

A nurse is caring for a client with type 1 diabetes on her first postpartum day. While planning care for this patient, what changes in insulin requirements does the nurse anticipate?

Sudden decrease Rationale: Insulin requirements may decrease suddenly after delivery. During the first 24 to 48 postpartum hours insulin requirements will neither increase or decrease slowly. Because the endocrine changes of pregnancy are reversed, insulin requirements do not usually remain unchanged in the postpartum period.

Which is a sign of a ruptured ectopic pregnancy in an adolescent?

abdominal pain and hypotension Rationale: An ectopic pregnancy occurs when a fertilized egg implants outside the uterus. Hypotension and abdominal pain indicates that the ectopic pregnancy might have ruptured. Ectopic pregnant cannot be diagnosed by normal labor pains. Ectopic pregnancy is ruled out if abdominal pain associated with bleeding or hypertension.

A client in labor at 39 weeks is told by the primary HCP that she will require a cesarean delivery. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth?

active genital herpes Rationale: Once the membranes have ruptures, the active herpes infection ascends and can infect the fetus; b/c herpes does not cross the placenta, a cesarean birth prevents transfer of the virus to the fetus. Gonorrhea, chlamydia, and chronic hepatitis are not indications for a cesarean birth; treatment is pharmacologic.

During a prenatal examination the nurse draws blood from an Rh negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for what?

acute hemolytic anemia Rationale: When an Rh-negative woman carries an Rh-positive fetus, there is a risk for the formation of maternal antibodies against the Rh-positive blood; antibodies cross the placenta and destroy the fetal red blood cells.

The nurse is caring for a client in active labor at a birth center. She is 100% effaced, dilated 3 cm, and at a +1 station. In which stage of labor is this client?

first Rationale: The client is in the first stage of labor b/c she is fully effaced but not yet completely dilated. The first stage lasts from the onset of contractions until full cervical effacement and dilation. The second stage of labor lasts from complete dilation to birth. Latent and transition are phases not stages of labor.

A 26 y/o G1 P0 client is seen in the clinic for her routine prenatal visit at 29 weeks gestation. On examination the nurse notes that she has gained 8 lbs since her last visit, 2 weeks ago; that her blood pressure is 150-90 mmHg; and that she has 1+ proteinuria on urine dipstick. What is the most likely diagnosis for this client?

mild preeclampsia Rationale: Preeclampsia is HTN that develops after 20 weeks gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mmHg and diastolic blood pressure is below 110 mmHg. Proteinuria is present, but there I snot evidence of organ dysfunction. Chronic HTN is HTN diagnosed before pregnancy or before 20 weeks. Gestation HTN is the onset of HTN during pregnancy without other S&S of preeclampsia.

A 25 weeks pregnant client who is being treated with tenormin reports labor pain. What medication would the primary HCP prescribe?

nifedipine Rationale: Nifedipine inhibits myometrial activity by blocking calcium channel reflux, which helps to reduce preterm labor.

A client is prescribed uterine stimulants to augment labor. Which condition should be assessed in the client before initiating therapy?

pelvic inflammatory disease Rationale: Labor-inducing drugs are contraindicated in women who have PID.

A nurse is teaching a prenatal class about the types of pain blocked that provide perineal anesthesia during labor. Which type of pain block should the nurse include the discussion that will provide perineal anesthesia but allow the client to feel contractions and push during the second stage of labor?

pudendal Rationale: The pudendal block relieves vaginal and perineal pain but does not impair the ability to push during the second stage of labor. The saddle block relieves pain from the umbilicus to the lower perineum and inner thigh; the client may have difficulty pushing during the second stage of labor. The epidural block relieves pain from the umbilicus to the midthigh; the client may have difficulty pushing during the second stage of labor. The paracervical block relieves uterine pain; it does not relieve perineal pain.

On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. How should the nurse respond?

"It seems like you've changed your mind about rooming in." Rationale: Stating that it seems the client has changed her mind opens communication and allows the client to verbalize her thoughts and feelings. Stating that the client is having difficulty caring for the baby is judgmental; there is not enough information for the nurse to make this assumption. Stating the intention of informing the other nurses of the client's decision does not give the client the opportunity to verbalize her feelings and needs. Although the Lucent may be tired, stating as much ignored the client's needs and cuts off communication.

The nurse is preparing to bathe a neonate born at 30 weeks of gestation. Which practices by the nurse ensure the infant's safety?

- immerse the neonate fully except the head in the tub - measures the body temperature within 2-4 hours before giving the bath - uses cleansing agents with neutral pH and minimal dyes while giving the bath Rationale: A neonate born before 32 week of gestational age is known as a preterm infant. Immersing the neonate's head in water during a bath can increase the risk of respiratory depression. The neonate's body temperature should be stable 2 to 4 hours before giving the initial bath. Therefore the nurse monitors body temperature before giving the bath. Cleansing agents with neutral pH and minimal dyes reduce skin irritation, so these are used when bathing the neonate. The nurse should give a warm-water bath every 2nd or 3rd day, not daily, to prevent hypothermia. Removing the vernix completely during the initial bath can alter thermoregulation in a neonate.

Women who become pregnant for the first time at a later reproductive age (35+) are at risk for which complications?

- preterm labor - multiple gestation - chromosomal anomalies - bleeding in the first semester Rationale: Increased risk for preterm labor is linked to age; it occurs more commonly in older primigravida and adolescents. Mature women have an increased incidence of multiple gestations as a restyles of fertility drug use and IVF. After 35 y/o, mature women have an increased risk of having children with chromosomal abnormalities. Bleeding in the first trimester as a result of spontaneous abortion is more common in mature gravid. Seizures are not more common in mature gravidas.

The nurse is performing a physical assessment of a pregnant woman. Which factor in the client's history increases the risk for abruptio placentae?

Hypertension Abruptio placentae occurs when the placenta prematurely separates from the uterus and occurs in about 1% of all pregnancies. The problem is more common in women with HTN; however, the causative factors are not clear. Hydramnios occurs about 10x more often in pregnancies involving clients with Type 1 DM. Spontaneous abortion, preterm labor and birth, and intrauterine fetal growth retardation are more common in pregnant clients with heart disease than those without it. There is not a higher incidence of abruptio placentae in clients with DM; clients with diabetes are more likely to experience preeclampsia or to go into preterm if they have diabetes before becoming pregnant, especially if pathologic changes related to diabetes are present.

The nurse manager receives a report on the following laboring clients. Which client should the nurse see first?

G6 P5 with intact membranes at 5 cm dilated Rationale: A grand multipara (5+) is at greater risk for precipitate labor and should be monitored more closely than a client with fewer deliveries and no other major risk factors.

Which intervention will be delayed until the newborn is 36-48 hours old?

screening for phenulketonuria Rationale: In 36-48 hours the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized b/c of a lack of a specific liver enzyme, can result in excessive levels of phenylalanine in the. blood stream and brain, resulting in cognitive impairment; early detection is essential to prevent this. The infant will have a Vit K shot soon after birth to prevent bleeding problems. Blood is withdrawn fro the heel soon after birth to test for hypoglycemia. Necrotizing enterocolitis is a disorder that can affect preterm infants. It is not identifies with the use of a test.