Maternal Infant Unit 5-9

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?

Answer: Naloxone

Which of the following would alert the nurse to suspect that a preterm newborn is in pain?

Sudden high-pitched cry Facial grimace Increased blood pressure, pulse, and respirations

When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm, accompanied by a decrease in variability and late decelerations. Which of the following would the nurse do next?

Answer: Notify the health care provider.

A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor?

Answer: Upright

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which of the following?

Answer: Variable decelerations

A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate?

"He should wet between 6 to 12 diapers each day."

A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman states that if she experiences any symptoms, she will do which of the following?

"I'll drink several glasses of water."

After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching?

"I'm going to have to wait a few days before I can start breast-feeding."

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate?

"Your body is undergoing many changes that cause your bladder to fill quickly."

The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth?

11

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?

"It varies, but you can estimate it returning in about 7 to 9 weeks."

After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful?

"Our newborn could develop a learning disability later on."

A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?

"The baby's sucking releases a hormone that causes the uterus to contract."

A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching?

"The cord stump should change from brown to yellow."

A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate?

"This is meconium stool, normal for a newborn."

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?

68 breaths per minute

The nurse is assessing a newborn and suspects that the newborn was exposed to drugs in utero because the newborn is exhibiting signs of neonatal abstinence syndrome. Which of the following would the nurse expect to assess? (Select all that apply.)

A) Tremors B) Regurgitation C) Shrill, high-pitched cry F) Frequent sneezing

A group of nursing students are reviewing information about cesarean birth. The students demonstrate understanding of the information when they identify which of the following as an appropriate indication? (Select all that apply)

A) Active genital herpes infection B) Placenta previa C) Previous cesarean birth E) Fetal distress

A newborn is experiencing cold stress. Which of the following would the nurse expect to assess? (Select all that apply.)

A) Respiratory distress C) Hypoglycemia E) Jaundice

The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. Which findings would the nurse most likely assess? (Select all that apply.)

A) Significant difficulty breathing C) Tachycardia D) Pulmonary edema E) Bleeding with bruising

A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk?

Appropriate-for-gestational-age (AGA). newborns

A nurse is documenting fetal lie of a woman in labor. Which term would the nurse most likely use?

Answer: Longitudinal

A group of nursing students are reviewing the various medications used for pain relief during labor. The students demonstrate understanding of the information when they identify which agent as the most commonly used opioid?

Answer: Meperidine

A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which of the following would the nurse expect to include when developing a plan of care for this woman? (Select all that apply.)

Answer: B) Avoidance of scalp electrodes for fetal monitoring C) Refraining from obtaining fetal scalp blood for pH testing D) Adminstering zidovudine at the onset of labor.

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which of the following would the nurse expect to include as part of the physical assessment? (Select all that apply.)

Answer: B) Fundal height measurement E) Membrane status F) Contraction pattern

Which position would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? (Select all that apply.)

Answer: Walking with partner support Straddling with forward leaning over a chair Rocking back and forth with foot on chair

Which of the following would be most appropriate for the nurse to suggest about pushing to a woman in the second stage of labor?

Answer: "Choose whatever method you feel most comfortable with for pushing."

A woman telephones her health care provider and reports that her "water just broke." Which suggestion by the nurse would be most appropriate?

Answer: "Come to the clinic or emergency department for an evaluation."

During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate?

Answer: "It's difficult to predict how your labor will progress, but we'll be there for you the entire time."

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor?

Answer: "The contractions slow down when I walk around."

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?

Answer: "The temperature of the water should be at least 105° F."

A nurse is explaining the use of therapeutic touch as a pain relief measure during labor. Which of the following would the nurse include in the explanation?

Answer: "This technique redirects energy fields that lead to pain."

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching?

Answer: "Unfortunately, I'm going to have to stay quite still in bed while it is in place."

A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as:

Answer: -2

When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR?

Answer: Between the umbilicus and the symphysis pubis

The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which of the following is the presenting part?

Answer: Buttocks

When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage?

Answer: Cervical dilation

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse reviews the woman's medical record to ensure which of the following as being required?

Answer: Cervical dilation of 2 cm or more

The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth?

Answer: Cesarean

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next?

Answer: Check the fetal heart rate.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next?

Answer: Continue to monitor the FHR because this pattern is benign.

The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first?

Answer: Feel for the fetal buttocks or head while palpating the abdomen.

A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping and lower back pain. The nurse determines that which of the following has most likely occurred?

Answer: Lightening

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. Which of the following would the nurse do first?

Aspirate the oral and nasal pharynx with a bulb syringe.

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus, expecting it to be at which location?

At the umbilicus

Teaching to a mother who just had a preterm labor to help prevent another.

Avoid traveling for long distances Wait at least 18 months between pregnancies.

A newborn has an Apgar score of 6 at 5 minutes. Which of the following is the priority?

Beginning resuscitative measures

After teaching a group of nursing students about risk factors associated with dystocia, the instructor determines that the teaching was successful when the students identify which of the following as increasing the risk? (Select all that apply.)

C) Short maternal stature D) Maternal age over 35 E) Breech fetal presentation

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the client's fundus?

Cannot be palpated

A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor. The nurse would be alert for which of the following in the newborn?

Caput succedaneum (cephalhematoma)

The nurse interprets which of the following as evidence that a client is in the taking-in phase?

Client states, "He has my eyes and nose."

The nurse places a warmed blanket on the scale when weighing a newborn. The nurse does so to minimize heat loss via which mechanism?

Conduction

Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy?

Covering the newborn's eyes while under the bililights

Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a "clunk" when Ortolani's maneuver is performed. Which of the following would the nurse suspect?

Developmental hip dysplasia

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?

Decrease the serum bilirubin level

A woman who is 42 weeks pregnant comes to the clinic. Which of the following would be most important?

Determining an accurate gestational age

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered?

Docusate (Colace)

After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation?

Dry the newborn thoroughly.

Expected findings with a post-term infant

Dry, cracked skin

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate?

Encourage the parents to touch their preterm newborn.

Assessment of a woman in labor who is experiencing hypertonic uterine dysfunction would reveal contractions that are:

Erratic

Drying the baby off and changing the diaper often helps prevent what type of heat loss?

Evaporation

A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition?

Fetopelvic disproportion

The nurse would be alert for possible placental abruption during labor when assessment reveals which of the following?

Gestational hypertension

The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has:

Greater surface area in proportion to weight

A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would assess for which of the following?

Hardening of an area in the affected breast

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's:

Heel

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which of the following?

Hematoma

Which of the following would the nurse expect to assess in a newborn who develops sepsis?

Hypothermia poor feeding persistent crying

A nurse is describing the risks associated with prolonged pregnancies as part of an inservice presentation. Which of the following would the nurse be least likely to incorporate in the discussion as an underlying reason for problems in the fetus?

Increased amniotic fluid volume

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which of the following in the mother and the newborn?

Infection

After presenting a class on measures to prevent postpartum hemorrhage, the presenter determines that the teaching was successful when the class states which of the following as an important measure to prevent postpartum hemorrhage due to retained placental fragments?

Inspecting the placenta after delivery for intactness

The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation?

Instructing her to apply ice packs to both breasts every other hour

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?

Knee-chest

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

Less than after a vaginal delivery

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse documents this finding as which of the following?

Mongolian spots

A newborn has been diagnosed with a Group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which of the following?

Mother's birth canal

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

Nasal flaring

After teaching a group of nursing students about tocolytic therapy, the instructor determines that the teaching was successful when they identify which drug as being used for tocolysis? (Select all that apply.)

Nifedipine Terbutaline Magnesium sulfate Indomethacin

After teaching a group of nursing students about a neutral thermal environment, the instructor determines that the teaching was successful when the students identify which of the following as the newborn's primary method of heat production?

Nonshivering thermogenesis

When assessing several women for possible VBAC, which woman would the nurse identify as being the best candidate?

One who had a previous cesarean birth via a low transverse incision

While caring for a preterm newborn receiving oxygen therapy, the nurse recognizing the need for follow up appointment with what specialist?

Ophthalmologist

The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary for which reason?

Oxygen demands need to be reduced.

A nurse is preparing an inservice education program for a group of nurses about dystocia involving problems with the passenger. Which of the following would the nurse most likely include as the most common problem?

Persistent occiput posterior position

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which of the following would the nurse expect to find?

Pinkish brown discharge

A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding?

Placing her hand in a basin of cool water

A nurse is developing a plan of care for a newborn with omphalocele. Which of the following would the nurse include?

Placing the newborn into a sterile drawstring bowel bag preventing heat loss maintaining perfusion to the eviscerated abdominal contents minimizing fluid loss protecting the exposed abdominal contents from trauma and infection

Which of the following would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn?

Provide opportunities for them to hold the newborn.

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds integrating understanding that this most likely is due to which of the following?

Relaxed cardiac sphincter

58 breaths per minute, O2 sat <82%, T 96.8

Respiratory distress

Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction?

Shortened

Which action would be most appropriate for the nurse to take when a newborn has an unexpected anomaly at birth?

Show the newborn to the parents as soon as possible while explaining the defect.

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following?

Stuffed animals should not be in areas where infants sleep.

When assessing a postterm newborn, which of the following would the nurse correlate with this gestational age variation?

Thin umbilical cord

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which of the following?

Thrombophlebitis

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus, expecting it to be at which location?

Two fingerbreadths below the umbilicus

A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which of the following findings would require immediate intervention?

Urine output of 20 mL/hour

A group of students are reviewing the causes of postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as the most common cause?

Uterine atony

A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also complains of acute abdominal pain that is continuous. Which of the following would the nurse suspect?

Uterine rupture

After teaching new parents about the sensory capabilities of their newborn, the nurse determines that the teaching was successful when they identify which sense as being the least mature?

Vision

When planning the care of a newborn addicted to cocaine who is experiencing withdrawal, which of the following would be least appropriate to include?

Waking the newborn every hour

A nursing student is preparing a presentation on minimizing heat loss in the newborn. Which of the following would the student include as a measure to prevent heat loss through convection?

Working inside an isolette as much as possible.

The nurse observes the stool of a newborn who has begun to breast-feed. Which of the following would the nurse expect to find?

Yellowish-brown, seedy stool

Way for the nurse to assess parent's ability to care for infant:

observing them

Appropriate info to include in discharge teaching:

ways to help baby stop crying