Growth and Development: OB & PEDS
The priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline is: 1 Massaging the uterine fundus 2 Helping the client to the bathroom 3 Assessing the peripad for the amount of lochia 4 Administering intramuscular methylergonovine (Methergine) 0.2 mg
1! A uterus that is displaced and above the fundus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine is administered.
After an emergency cesarean birth, the client tells the nurse that she was hoping for a "natural" childbirth but is glad that she and her baby are all right. Which postpartum phase of adjustment does this statement most closely typify? 1 Taking-in 2 Letting-go 3 Taking-hold 4 Working-through
1! By discussing the 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 the tasks of the taking-in and taking-hold phases have been completed. The taking-hold phase is marked by an increased desire to resume independence. The working-through phase is not a separate phase of adjustment to parenthood; this is not relevant.
A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond? 1 "During the eighth week of the pregnancy." 2 "At the end of the second week of pregnancy." 3 "When the fertilized egg becomes implanted." 4 "When the products of conception are seen on the sonogram."
1! During the eighth week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth. At the end of the second week of pregnancy, the developing cells are called an embryo. At the time of implantation, the group of developing cells is called a blastocyst. The embryo can be visualized on ultrasound before it becomes a fetus.
On reporting to the labor and delivery area a primipara indicates to the nurse that her contractions are occurring every 5 minutes. Upon further inquiry the nurse learns that the client has not attended any childbirth classes, and a cervical assessment reveals that she is in labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques? 1 During the latent phase of the first stage of labor 2 During the active phase of the first stage of labor 3 During the active phase of the second stage of labor 4 During the transition phase of the first stage of labor
1! 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 between 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 of labor the contractions are at their maximum intensity, which inhibits the client's ability to listen.
The nurse is assessing the Apgar scores of four different newborns in a pediatric ward. Which child does the nurse anticipate is experiencing severe distress? 1 Newborn A The newborn has a heart rate of 75 bpm, irregular and weak cry, limp muscle tone, no reflex irritability, and blue skin tone 2 Newborn B The newborn has a heart rate of 120 bpm, strong cry, well flexed muscle tone, sneezing reflex, and completely pink skin. 3 Newborn C The newborn has a heart rate of 80 bpm, weak cry, slight flexion in extremities, grimacing face, and pink body with blue extremities. 4 Newborn D The newborn has a heart rate of 100 bpm, strong cry, small flexion in extremities, grimacing face, and pale body.
1! Newborn A has a heart rate of 75 beats/minute, which is given a score of 1. The newborn's cry is irregular and weak, which receives a score of 1. The newborn has limp muscle tone, which scores a 0; no reflex irritability, which is also given a score of 0; and blue skin tone, which is given a score of 0. The total Apgar score of Newborn A is 2. Therefore, Newborn A has severe distress. The total Apgar score of Newborn B is 10, indicating no difficulty adjusting to the new environment. The total Apgar score of Newborn C is 5. Therefore, Newborn C has moderate difficulty adjusting. The total Apgar score of Newborn D is 6. Therefore, Newborn D has moderate difficulty adjusting. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the patient in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test-taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.
A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. The nurse recalls that the basis of obsessive-compulsive disorder is often feelings of: 1 Anxiety and guilt 2 Anger and hostility 3 Embarrassment and shame 4 Hopelessness and powerlessness
1! Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.
An 18-year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that flunitrazepam is often used: 1 As a date rape drug 2 To control symptoms of psychosis 3 To control symptoms of bipolar mania 4 To treat hangover symptoms after excessive alcohol consumption
1! Rohypnol (flunitrazepam), illegal in the United States, has been used in date rapes; the victim is attacked after consuming a drink spiked with the drug. Flunitrazepam is not used to treat psychosis, mania, or hangover symptoms.
A child is born to a mother whose hepatitis B status is negative. While assessing the newborn, the nurse finds that the birth weight is 1.8 kg. Which action by the nurse is appropriate in this situation? 1 Administer HepB vaccine to the newborn 1 month after birth. 2 Administer 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. 3 Administer monovalent HepB vaccine to the newborn during discharge. 4 Administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth.
1! The immune response to the HepB vaccine is not optimum in newborns weighing less than 2 kg. As the mother's hepatitis B status is negative, the first dose of HepB vaccine should be administered 1 month after birth. There is no need to administer 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth, as the mother's hepatitis B status is negative. Monovalent HepB vaccine is administered during discharge to newborns whose birth weight is more than 2 kg. If the infant were born to a hepatitis-positive mother, HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) would be administered within 12 hours of birth. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
The nurse is assessing a newborn immediately after birth. Which finding indicates normal development in a newborn? 1 A body weight of 3500 g 2 A core body temperature of 96° F 3 Blood pressure of 70/60 mm Hg 4 Head circumference is 3 cm less than chest circumference
1! The newborn has a body weight of 3500 g, which is within the normal range of 2700 to 4000 g. Therefore, this indicates normal development. The core body temperature of the newborn is 96° F, which is lower than the normal range of 97.7° F to 99.7° F. Therefore, the core body temperature of 96°F indicates hypothermia. The normal blood pressure of a newborn on the first day of birth is 65/45 mm Hg. A blood pressure finding of 70/60 mm Hg indicates very high blood pressure. The head circumference of the newborn is less than the chest circumference, which indicates that the newborn may have microcephaly.
Which reflex does the nurse assess in a newborn to determine auditory ability? 1 Startle reflex 2 Rooting reflex 3 Glabellar reflex 4 Extrusion reflex
1! To assess auditory ability in a newborn, the nurse makes a sudden loud sound, which causes the newborn's arms to abduct. This reflex is called the startle reflex. When assessing the rooting reflex, the nurse strokes the child's cheek, and the child's head turns to the same side in response. When assessing the glabellar reflex, the nurse taps the tip of the child's nose, and the child's eyes close in response. When assessing the extrusion reflex, the nurse touches the child's tongue, and the child forces it out in response. The rooting reflex, glabellar reflex, and extrusion reflex do not help determine auditory ability.
A client is admitted to the hospital with signs and symptoms of obstruction of the common bile duct. Laboratory test results indicate prolonged bleeding and clotting times. What can the nurse conclude these test results indicate? 1 Vitamin K is not being absorbed. 2 Ionized calcium level is decreased. 3 Bilirubin in the plasma is increased. 4 Extrinsic factor is not being absorbed.
1! Vitamin K, a fat-soluble vitamin, is not absorbed from the gastrointestinal tract in the absence of bile; bile enters the duodenum via the common bile duct. Calcium is related to rhythmic muscle contraction, not coagulation. Bilirubin is formed by the breakdown of hemoglobin and red blood cells and is not related to coagulation. The extrinsic factor (cyanocobalamin) is a water-soluble vitamin; bile is not necessary for its absorption.
A woman in labor with no known complications rings the call bell to say she has had a "gush" from her vagina. The nurse identifies a large amount of bright-red blood. In what order should the nurse perform these interventions? 1. Start oxygen at 8 L/mask. 2. Call for help. 3. Check fetal heart tones. 4. Call the health care provider. 5. Increase the maintenance IV infusion rate.
1. Call for help 2. Check fetal heart tones. 3. Increase the maintenance IV infusion rate. 4. Start oxygen at 8 L/mask 5. Call the health care provider. Calling for help will allow all other actions to be completed more quickly. This is especially critical during an emergency situation. Next the nurse should assess the fetal heart tones to identify the effect of the bleeding on the fetus, because the fetus often shows signs of distress before the mother does. After checking the fetal heart tone the nurse should increase the IV infusion rate, which should take only seconds and can have a significant effect on circulation. Oxygen can be instituted after the IV infusion rate has been increased; this will be of benefit to both mother and fetus. Calling the primary health care provider is important, but instituting lifesaving measures takes precedence.
In childbirth classes the nurse is teaching paced breathing techniques for use during labor. In which order should the breathing techniques be used as labor progresses? 1. Slow, deep breaths 2. Cleansing breaths 3. Pant-blow breathing 4. Slow, exhalation pushing 5. Modified-paced breathing
1. Cleansing breaths 2. Slow, deep breaths 3. Modified-paced breathing 4. Pant-blow breathing 5. Slow, exhalation pushing Cleansing breaths, in which the woman breathes in through the nose and out through the mouth, are used at the beginning and end of each contraction. Slow, deep breaths are used early in the first stage of labor to promote relaxation of abdominal muscles. Modified paced breathing may be used when the woman can no longer walk or talk through contractions; it requires concentration and promotes relaxation and oxygenation. As contractions increase in frequency and intensity, more complex breathing techniques require enhanced concentration and therefore block painful stimuli more effectively. Patterned, paced breathing, such as pant-blow, is used during the transition phase of the first stage of labor. Slow exhalation pushing is used during the second stage to facilitate a controlled birth, minimizing maternal trauma and the need for an episiotomy.
A routine urinalysis is prescribed for a client. What should the nurse do if the specimen cannot be sent immediately to the laboratory? 1 Take no special action. 2 Refrigerate the specimen. 3 Store it in the dirty utility room and send it later. 4 Discard the specimen and collect another specimen later
2! Refrigeration retards the growth of bacteria and may preserve the specimen for several hours. Growth of bacteria will alter the pH and the glucose and protein levels in the urine; it must be refrigerated to retard growth. Discarding the specimen and collecting another specimen later represents an unnecessary waste of time, effort, and money.
A nurse is admitting a pregnant client who has mitral valve stenosis to the high-risk unit. What prophylactic medication does the nurse anticipate administering during the intrapartum period? 1 Diuretic 2 Antibiotic 3 Cardiotonic 4 Anticoagulant
2! 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 male client who is taking clozapine (Clozaril) is seen by the nurse in the outpatient mental health clinic. The nurse interviews the client, sends a venous blood specimen to the laboratory, obtains the vital signs, and finally reviews all the collected information. Which complication associated with clozapine does the nurse suspect that the client is experiencing? 1 Anemia 2 Agranulocytosis 3 Orthostatic hypotension 4 Neuroleptic malignant syndrome
2! Clozapine (Clozaril) can cause bone marrow suppression. The expected white blood cell (WBC) value for an adult is 4500 to 10,000 mm3. The client has a reduction in WBCs, making him vulnerable to infection. A fever with complaints of a sore throat and weakness supports the conclusion that the client may have an infection. The red blood cell (RBC) count does not indicate anemia. The expected range of RBCs for an adult male is 4.6 to 6.2 ´ 106/mL3. The small change in the blood pressure from standing to sitting does not support the conclusion of orthostatic hypotension. Labile hypertension is associated with neuroleptic malignant syndrome. There are insufficient data to support the conclusion that the client is experiencing neuroleptic malignant syndrome. Although tachycardia and tachypnea are associated with neuroleptic malignant syndrome, the client's fever would be more than 100.6° F (38.1° C). Additional characteristics of neuroleptic malignant syndrome include labile hypertension, diaphoresis, drooling, increased muscle tone, and decreased level of consciousness.
The postpartum nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task should the nurse delegate to UAP? 1 Evaluation of a postpartum client's lochia 2 Vital signs on a client 4 hours after delivery 3 Assessment of a postpartum client's episiotomy 4 Assisting the postpartum client to breastfeed for the first time
2! Evaluating the client's lochia, assess the client's episiotomy, and helping the client breastfeed for the first time would involve assessment, teaching, or evaluation and should not be delegated. The only task that does not require any of these is taking vital signs 4 hours after delivery.
The nurse is assessing a newborn whose parents are Asian. The nurse finds that the child has irregular, deep-blue pigmentation on the gluteal regions. What does the nurse interpret from these findings? 1 The child has milia. 2 The child has mongolian spots. 3 The child has erythema toxicum. 4 The child has harlequin color change
2! Mongolian spots are a medical condition characterized by the appearance of irregular, deep-blue pigmented spots on the gluteal regions. This skin abnormality is a common finding in newborns of Asian descent. Milia are distended sebaceous glands, which manifest as tiny white papules on cheeks, chin, and nose. Erythema toxicum manifests as a pink papular rash on the thorax, back, and buttocks. Harlequin color change is a clear line through the body caused by lying on one side. The side on which the baby sleeps turns pink.
The postpartum nurse has just received report on four clients. Which client should the nurse care for first? 1 Client who vaginally delivered a 7-lb baby 1 hour ago 2 Client who vaginally delivered a 9-lb baby 1 hour ago 3 Client who vaginally delivered a preterm baby 4 hours ago 4 Client who had a planned cesarean delivery of an 8-lb baby 2 hours ago
2! The nurse should assess the client at risk for postpartum hemorrhage first. Uterine atony after a vaginal delivery is the main cause of postpartum hemorrhage. An overdistended uterus caused by a large fetus (9-lb baby) can cause uterine atony. Delivering a 7-lb baby or a preterm baby is not a risk factor. Uterine atony is minimized in a planned cesarean delivery.
A nurse is planning a childbirth education class about maternal psychological and physiological changes as pregnancy nears term. Which problems and concerns should the nurse include in the presentation? Select all that apply. 1 Food cravings increase. 2 Nesting needs increase. 3 Dependency needs decrease. 4 Anxiety about childbirth increases. 5 Gastrointestinal motility decreases
2, 4, and 5! Nesting needs increase as pregnancy reaches term; it is a psychological preparation for motherhood. As pregnancy nears term, maternal thoughts turn to the problems that may occur during labor and birth. Because the enlarged uterus is pressing on the organs of the gastrointestinal tract, digestive and elimination problems increase. Food cravings start early in the pregnancy and do not commonly intensify as the pregnancy nears term. Maternal dependency needs increase as the pregnancy nears term; there is a need for being nurtured in preparation for providing it to the newborn.
The nurse is assessing a newborn and anticipates that the newborn has renal impairment. Which finding supports the nurse's conclusion? 1 The newborn has colorless urine. 2 The newborn has odorless urine. 3 The newborn first voids after 76 hours. 4 The newborn's urine has specific gravity of 1.020.
3! A newborn should void within 24 hours. However, in this case, the newborn first voids after 76 hours, indicating renal impairment. The urine should be colorless and odorless. This indicates that the urine is normal and the child has normal renal function. Normally the specific gravity of urine is 1.020.
A client comes to the clinic for a 6-week postpartum checkup. 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? 1 Providing client information about a local support group 2 Explaining that it is normal to feel depressed after childbirth 3 Asking the client questions, using a postpartum depression scale 4 Suggesting that the client find someone who can take care of the baby for 24 hours
3! A postpartum depression scale is a validated tool for identifying women who might be experiencing postpartum depression. Although providing community resources of a local support group may be helpful, it is not helpful in assessing the client's current emotional status. Although postpartum blues due to 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 primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show. She and her partner attended childbirth preparation classes. Vaginal examination reveals that the cervix is dilated 3 cm and 75% effaced. The fetus is at +1 station in occiput anterior position, and the membranes are intact. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. In light of the nurse's observations regarding the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond? 1 "I can't make a decision on that; I'll have to ask your health care provider." 2 "Please stay in bed; walking could interfere with effective uterine contractions." 3 "It's all right for you to walk as long as you feel comfortable and your membranes are intact." 4 "You may sit in a chair, because your contractions cannot be timed when you walk and I won't be able to listen to the baby's heart."
3! Contractions become stronger and more regular when the woman is standing; also, as the woman walks the diameter of the pelvic inlet increases, allowing easier entrance of the head into the pelvis. Judging from the information gleaned during the admitting assessment the nurse is qualified to make this decision. The contractions of true labor are enhanced when the mother walks. Timing and Doppler auscultation of the fetal heart rate may be continued even if the client chooses to walk.
During a childbirth class, several participants have questions about the elective induction of labor. One participant states that it is more convenient for a woman with a busy schedule. What evidenced-based information should the nurse provide to the participant? 1 "Elective induction rates are dropping nationwide." 2 "Elective induction is recommended if the client has a classic uterine incision." 3 "The widespread use of elective induction increases the risk of unfavorable outcomes." 4 "There is no evidence that elective induction makes any difference in the labor experience."
3! Elective induction significantly increases the risk of cesarean birth, instrumented delivery, use of epidural analgesia, and neonatal intensive care unit admission, all of which may or may not produce a favorable outcome. Elective induction rates are increasing on a national basis. There are some very important reasons, including convenience for the client, obstetrician, or both, that some women should have labor induced. A classic (vertical) uterine incision would be a contraindication to any type of vaginal delivery, whether spontaneous or induced. Rupture of the uterus and possible death would be dangerous side effect, so cesarean section would be scheduled in advance of labor.
After reviewing the laboratory reports of a 3-month-old infant, the nurse confirms hyponatremia in the infant. Which statement from the infant's parent supports the nurse's confirmation? 1 "I avoid giving my child honey." 2 "I avoid giving my child fruit juice." 3 "I give my child purified water in the afternoon." 4 "I give my child a daily vitamin D supplement of 400 IU."
3! Giving excess water to infants less than 4 months of age can result in hyponatremia and water intoxication in the infant. Therefore, the parents should not give water to the infant until 4 months of age. Honey does not maintain a normal electrolyte balance in the infant; therefore, avoiding giving the infant honey does not result in hyponatremia. Fruit juices can result in hyponatremia; therefore, the infant should not be given fruit juice until 4 months of age. A daily vitamin D supplement of 400 IU does not reduce sodium levels in the infant; it prevents rickets. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
When assessing a neonate immediately after birth, the nurse observes an inability to close the eyes completely. The nurse also observes drooping of the corner of the neonate's mouth, and the absence of wrinkling of the forehead and nasolabial fold. What does the nurse infer from these findings? 1 The neonate has bleeding in the subgaleal layer during labor. 2 The neonate has cranial nerve V pressurized during labor. 3 The neonate has cranial nerve VII pressurized during labor. 4 Exposure to vaginal gonorrheal infection during labor.
3! Inability to close the eyes completely, drooping of the corner of mouth, and absence of wrinkling of the forehead and nasolabial fold indicate facial paralysis. When the facial nerve, or cranial nerve VII, is pressurized during labor, it can result in facial paralysis. Bleeding in the subgaleal layer indicates subgaleal hemorrhage in a neonate. Subgaleal hemorrhage is not characterized by inability to close the eyes, drooping of the corner of mouth, or absence of wrinkling of the forehead and nasolabial fold. Cranial nerve V does not innervate the face, so damage to cranial nerve V does not result in facial paralysis. A neonate who is exposed to vaginal gonorrheal infections during labor may develop ophthalmia neonatorum, not facial paralysis.
While caring for a pregnant patient with 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? 1 Erb palsy 2 Klumpke palsy 3 Strawberry hemangioma 4 Erythema toxicum neonatorum
3! Maternal body mass index 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 or Erb-Duchenne paralysis in the neonate. Klumpke palsy can result due to severe stretching of the upper extremities, while the trunk is relatively less mobile during labor. A maternal body mass index greater than 30, a second stage of labor lasting less than 15 minutes, and infant birth weight higher than 4000 g are not indicators of strawberry hemangioma or erythema toxicum neonatorum.
he nurse is assessing newborns 24 hours after birth in a pediatric health care setting. Which neonate requires priority action from the nurse? 1 Neonate 1 Weight: 3 kg Output: 66 mL 2 Neonate 2 Weight: 2.4 kg Output: 60 mL 3 Neonate 3 Weight: 3.8 kg Output: 46 mL 4 Neonate 4 Weight: 2.5 kg Output: 40 mL
3! Neonates produce and excrete approximately 15 to 60 mL of urine per kilogram every 24 hours. Therefore, a neonate who weighs 3.8 kg should produce and excrete 57 to 228 mL of urine every 24 hours. Urinary output of 46 mL in a 3.8-kg infant indicates oliguria. Normal urinary output for a neonate who weighs 3 kg should be 45 to 180 mL every 24 hours, so urinary output of 66 mL in a 3-kg neonate is normal. Normal urinary output for a neonate weighing 2.4 kg is 36 to 144 mL of urine every 24 hours, so 60 mL urinary output in a 2.4-kg infant does not indicate oliguria. Urinary output for a 2.5-kg neonate should be 37.5 to 150 mL of urine every 24 hours, so urinary output of 40 mL in a 2.5-kg infant does not indicate oliguria. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the patient in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test-taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.
Which finding indicates that a newborn has vernix caseosa? 1 Brown hair on the skin 2 Rosy to yellowish skin 3 Cheese-like substance on the skin 4 Light-pink to reddish-brown skin
3! Sebum and desquamating cells on the newborn's skin give it a white, cheesy appearance, which is called vernix caseosa. Brown hair on a newborn's skin is called lanugo. Newborns of Asian descent will have rosy to yellowish skin. Light-pink to reddish-brown skin indicates that the newborn is of Native American descent.
A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. How does the nurse, using the GTPAL format, document the client's obstetric history? 1 G4 T3 P2 A1 L4 2 G5 T2 P2 A1 L4 3 G5 T2 P1 A1 L4 4 G4 T3 P1 A1 L4
3! The acronym GTPAL stands for gravidity, term births, preterm births, abortions, and living children; G5 T2 P1 A1 L4 indicates that there the client has had five pregnancies (twins count as one pregnancy and the current pregnancy counts as one); two term births; one preterm birth (the twins); one abortion; and four living children. G4 T3 P2 A1 L4 indicates that there were four, not five, pregnancies; three, not two, term births; twins counted as one, not two, preterm birth; one abortion; and four living children. G5 T2 P2 A1 L4 indicates that there were five pregnancies; two term births; twins counted as one, not two, preterm births; one abortion; and four living children. G4 T3 P1 A1 L4 indicates that there were four, not five, pregnancies; three, not two, term births; twins counted as one preterm birth; one abortion; and four living children.
A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. A licensed practical nurse/licensed vocational nurse (LPN/LVN) and aide are also working on the unit. Which nursing action is best delegated to the LPN/LVN? 1 Discharge teaching for a client who delivered her third infant girl 2 days ago 2 Delivering a clear-liquid dietary tray to a client who had a cesarean section 4 hours ago 3 Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10 4 The initial assessment of a client who just delivered an 8 lb 12 oz (3970 g) infant over an intact perineum
3! The pain assessment has been performed and the RN will need to evaluate the effectiveness of the pain medication. However, the administration of oral pain medication is within the scope of practice for an LPN/LVN. Initial teaching and assessment are within the scope of practice for only the RN and may only be delegated to another RN. A meal tray may be delivered by an unlicensed person such as an aide or a dietary employee.
A primipara about to be discharged with her newborn asks the nurse many questions regarding infant care. What phase of maternal adjustment does this behavior illustrate? 1 Let-down 2 Taking-in 3 Taking-hold 4 Early parenting
3! The taking-hold phase, which begins about the second or third postpartum day, involves concern about being a "good" mother; the new mother is most receptive to teaching at this time. Let-down is not related to bonding. The let-down reflex refers to the flow of milk in response to suckling and is caused by the release of oxytocin from the posterior pituitary. The taking-in phase is the first period of adjustment to parenthood. It includes the first 2 postpartum days; the mother is passive and dependent and preoccupied with her own needs. The behavior described refers to the taking-hold phase of bonding. Early parenting involves many behaviors, of which taking-hold is only one.
A 37-year-old client with type 1 diabetes and good glycemic control is pregnant for the third time. Her first child is 4 years old, and her second pregnancy resulted in a stillbirth. She is seen in the antepartum testing unit for a nonstress test (NST) at 33 weeks' gestation. What are the primary risk factors in the client's history that indicate a need for the NST? Select all that apply. 1 Age greater than 35 years 2 The risk for placenta previa 3 The risk for placental insufficiency 4 A history of stillbirth from her last pregnancy 5 Maternal history of hypertension
3,4, and 5! Pregnant women with diabetes are prone to placental insufficiency, which can threaten fetal well-being. In addition, history of stillbirth is also an indication for NST. In addition, maternal conditions that can affect placental perfusion such as hypertension is an indication for a NST. Advanced maternal age alone is not an indicator for an NST; although advanced maternal age increases the risk of placenta previa, it is not the primary reason for having an NST.
The nurse is planning care for a client with postpartum psychosis. Which priority intervention should the nurse plan to implement? 1 Teaching the client about normal newborn care 2 Ensuring adequate bonding time with the infant 3 Giving the client time and space to express her feelings 4 Referring the client to a psychiatric health care provider as prescribed
4! Assessment and management of postpartum psychosis are beyond the scope of a maternity nurse, and a mother who experiences this condition must be referred to a specialist for comprehensive therapy. Women with signs of postpartum psychosis need immediate medical attention to prevent suicide or infanticide. In light of this psychiatric emergency condition it would not be appropriate to plan bonding time for the client and infant, teach her about normal newborn care, or allow expression of her feelings.
After assessing a 4-day-old newborn, the nurse anticipates that the newborn has impaired vision. Which finding supports the nurse's conclusion? 1 The newborn has visual acuity of 20/100. 2 The newborn blinks in response to light. 3 The newborn does not produce tears while crying. 4 The newborn has no corneal reflex after a light touch.
4! Corneal reflex in infants is activated by a light touch. Therefore the nurse anticipates that the newborn has impaired vision when there is no corneal reflex after a light touch. Visual acuity of 20/100 in a newborn is a normal finding; it does not indicate that the newborn has impaired vision. A positive blink reflex in response to stimulus is a normal finding; it does not indicate that the newborn has impaired vision. The tear glands begin functioning 2-4 weeks after birth. The absence of tears while crying is a normal finding in newborns and does not indicate that the newborn has impaired vision.
What should the nurse discuss with new parents to help them prepare for infant care? 1 Allowing crying time to help the lungs develop 2 Establishing a set feeding schedule to promote steady weight gain 3 Counting the number of stool diapers daily to confirm adequate hydration 4 Learning specific behaviors involving states of wakefulness to promote positive interactions
4! Discussing behaviors during the baby's waking times that will promote positive interaction helps parents understand the unique features of their newborn and promotes interaction and care during periods of wakefulness. A healthy infant's lungs are developed at birth. It is best that infants be on a demand feeding schedule, not a routine schedule. Demand feeding provides for individuality; healthy infants gain weight steadily. Counting the number of stool diapers daily is not a reliable method of determining adequate hydration.
During a childbirth preparation class, the nurse teacher discusses the importance of the spurt of energy that occurs before labor. Why is it important to conserve this energy? 1 Fatigue may increase the progesterone level. 2 Extra energy decreases the intensity of contractions. 3 Extra energy is needed to push during the first stage. 4 Fatigue may influence pain medication requirements.
4! Fatigue will interfere with the successful use of other coping strategies such as distraction; this may lead to the client's need for pain medication. Neither fatigue nor energy influences the progesterone level, which is decreased at this time. Energy will increase the intensity of contractions. The client does not push during the first stage of labor; pushing is done during the second stage.
A pregnant couple is attending preparation-for-childbirth classes. Which exercise should the nurse teach the mother to increase the tone of the muscles of the pelvic floor? 1 Pelvic tilt 2 Half sit-ups 3 Pelvic rocking 4 Kegel exercises
4! Kegel exercises increase the tone of pelvic floor muscles and prepare the area for the second stage of labor. Pelvic tilting alleviates backache and strengthens the abdominal muscles, not the muscles of the pelvic floor. Half sit-ups strengthen the abdominal musculature, not the muscles of the pelvic floor. Pelvic rocking alleviates backache and strengthens abdominal muscles, not the muscles of the pelvic floor.
A nurse is teaching a childbirth preparation class. Which exercise should the nurse teach the women for toning the pelvic floor? 1 Pelvic tilt 2 Half sit-ups 3 Pelvic rocking 4 Kegel exercises
4! Kegel exercises tone the pelvic floor muscles and prepare the area for the second stage of labor. The other options alleviate backache and strengthen the abdominal muscles.
A mother in the postpartum unit expresses concern that her 3-year-old daughter will be jealous of her new brother. What should the nurse suggest? 1 Ignoring negative comments that the daughter makes about the baby 2 Allowing the daughter to stay with her baby brother when the mother rests 3 Explaining in simple terms why the mother must spend more time with the baby 4 Bringing home a new baby doll for the daughter when her baby brother is brought home
4! Providing a doll for the child can encourage role-play with the new doll, which is an age-appropriate activity. The child can tend to the doll's needs while the parent performs similar activities and use this practice to progress to helping with the newborn. Ignoring the child's comments will reinforce insecurity and may promote acting-out behavior. The child is too young to be left alone with an infant. Telling the child that the mother must stay with the baby rather than with her may increase the child's feelings of jealousy.
A postpartum nurse is providing care to four maternal/infant couplets. After receiving handoff report from the off-going nurse, which client will the nurse see first? 1 The term infant with a heart rate of 158 beats/min 1 hour after birth 2 The mother who has saturated one peripad over the 4 hours since delivery 3 The mother with a white blood cell count of 12,500/mm3 24 hours after delivery 4 The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL 12 hours after birth
4! 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 white blood cell count increase is normal after birth, possibly a result of to stress and tissue trauma during the birthing process. 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 less than the acceptable limit.
A laboring client who is positive for Group B Streptococcus is given an initial dose of ampicillin (Omipen) 2 g at 9 am. According to established guidelines for intrapartum management of this client, the next dose should be: 1 2 g given at 10 am 2 1 g given at 11 am 3 2 g given at noon 4 1 g given at 1 pm
4! The established guidelines for Intrapartum antibiotic prophylaxis (IAP) for a client infected with GBS is an initial dose of 2 g followed by a 1-g dose every 4 hours.
A nurse on the postpartum unit is providing postpartum care instructions to a 21-year-old Hispanic woman who delivered her first baby yesterday without complications. Her husband, mother, and other family members have been with her since delivery. The mother speaks and understands very little English, but her husband and sister speak some English. What is the best way to ensure that the client and her family understand what is being said? 1 Providing the teaching to all family members and the client 2 Asking the client and her family to nod their heads to verify understanding 3 Asking the client and her family members to say yes to verify understanding 4 Asking the client and family members to repeat, in their own words, what they have been told
4! The family members should tell the nurse their understanding of what was taught. Nodding or saying yes may be a sign of courtesy rather than of understanding or agreement and is not an effective way to verify understanding. Simply providing the teaching to the family does not ensure understanding.
The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says she just can't do it." What is the best response by the nurse? 1 Encouraging him to express his feelings about the situation 2 Telling him to schedule an appointment with the gynecologist 3 Asking whether he can afford a home health aide for several weeks 4 Informing him that he should seek emergency intervention for his wife
4! The inability to care for herself or her infant is a significant sign that the wife is depressed and in need of immediate intervention. The wife, not the husband, is the priority at this time. The wife has an emotional, not physiological, problem at this time. Asking whether the family can afford a home health aide for several weeks is not the priority at this time; the wife's emotional condition is the priority. Test-Taking Tip: Look for answers that focus on the client or that are directed toward the client's feelings.
Oral phenobarbital 30 mg every 6 hours is prescribed for a toddler who has had a seizure. A bottle of phenobarbital liquid labeled "20 mg/4 mL" is available. How much solution (mL) should the nurse administer? Record your answer using a whole number. ___ mL
6!
After assessing a newborn infant, the nurse finds that the infant has a heart rate of 90 beats/minute, irregular respirations with a weak cry, limp extremities, sneezing reflex, and a completely pink body. What would be the Apgar score of the child? Record your answer using a whole number. ______
6! The infant has a heart rate of 90 beats/minute, which is given a score of 1. The infant also has irregular respiration with a weak cry, which is scored as 1. The infant has limp extremities, which receives a score of 0. The infant has the sneezing reflex, which is given a score of 2. The infant has a completely pink body, which is also given a score of 2. Therefore, the total Apgar score of the infant is 1 + 1 + 0 + 2 + 2 = 6. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.
