Maternal Prepu Questions Test 1 : (Ch.4, 5, 11, 12, 13, 14, 15, 16, 17, 18, 20, and 22)

Subfertility/infertility is said to exist when a couple has failed to achieve pregnancy after how many months of unprotected sexual intercourse?

12 months Infertility is the failure to achieve conception after 1 year of unprotected intercourse.

How many days is the neonatal period for a newborn?

28 days

After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment? A. "I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months." B. "We will be discussing birth control with our primary care provider to find the best method for us." C. "We're going to use a barrier for the first few months and then decide what we want to do." D. "I'm going back on the pill as soon as the doctor okays it."

A. "I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months." Breastfeeding is not a totally reliable method of contraception unless the mother exclusively breastfeeds, has had no menstrual period since giving birth, and whose infant is younger than 6 months old; however, ovulation may occur before menstruation.

A woman seen in the emergency walk-in clinic is diagnosed with chlamydia trachomatis. She asks the nurse how this disease is different from other sexually transmitted infectious diseases. What is the nurse's best response? A. "This STI is characterized by an infection of your cervix." B. "This STI is an infection that will cause itching in the genital area." C. "This STI is an infection that results in ulcers in the genital area." D. "This STI is an infection that will result in the formation of genital warts."

A. "This STI is characterized by an infection of your cervix." Explanation: STIs like chlamydia result in a cervicitis that implies the presence of inflammation or infection of the cervix. It produces quantities of purulent discharge. Cervicitis is usually caused by gonorrhea or chlamydia. Chlamydia will not produce ulcers or warts and is not a STI that has itching associated with it.

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? A. 500 additional calories per day B. 1,000 additional calories per day C. 250 additional calories per day D. 750 additional calories per day

A. 500 additional calories per day

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema? A. Apply ice. B. Use ointments locally. C. Apply moist heat. D. Use a warm sitz bath or tub bath.

A. Apply ice. Ice is applied to perineal edema within 24 hours after birth. Use of ointments is not advised for perineal edema. Moist heat and a sitz or tub bath are encouraged if edema continues 24 hours after birth.

The nurse is caring for a client who is experiencing a noneventful labor process. Which assessment findings may occur as the client progresses through the stages of labor? Select all that apply. A. Dry mucous membranes B. Nausea C. Diuresis D. Increased white blood cell count E. Increased urine specific gravity F. Hyperventilation

A. Dry mucous membranes B. Nausea D. Increased white blood cell count E. Increased urine specific gravity F. Hyperventilation The nurse is correct to identify that normal changes occur during the labor process. Due to mouth breathing and drinking limited fluids, if any, dehydration with dry mucous membranes and an elevated urine specific gravity are common. Since labor prolongs gastric emptying, the client may experience nausea. An increase in the white blood cell stemming from the immune response is common. Concentrated urine and decreased urine production are common, not diuresis.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? A. Epstein's pearls B. milia C. stork bites D. Mongolian spots

A. Epstein's pearls Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein's pearls.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? A. duration B. intensity C. frequency D. peak

A. duration Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.

What is the most common viral infection? A. human papillomavirus (HPV) B. gonorrhea C. chlamydia D. trichomoniasis

A. human papillomavirus (HPV)

A nurse is explaining how hormones affect the pregnancy. Which hormone would the nurse describe as being responsible for stimulating uterine contractions during labor and birth? A. oxytocin B. progesterone C. estrogen D. prolactin

A. oxytocin Oxytocin is responsible for stimulating the uterine contractions that bring about delivery. Progesterone and estrogen help maintain the pregnancy, and prolactin helps with stimulating milk production after the delivery

The Ballard scoring system evaluates newborns on which two factors? A. physical maturity and neuromuscular maturity B. skin maturity and reflex maturity C. tone maturity and extremities maturity D. body maturity and cranial nerve maturity

A. physical maturity and neuromuscular maturity When determining a newborn's gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics.

A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? A. reflex B. crying response C. voluntary movements D. orientation to surroundings

A. reflex The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.

Pelvic infection is most commonly caused by: A. sexual transmission. B. surgical abortion. C. hysteroscopy. D. insertion of intrauterine device.

A. sexual transmission. Explanation: Pelvic infection is most commonly caused by sexual transmission but can also occur with invasive procedures such as endometrial biopsy, surgical abortion, hysteroscopy, or insertion of an intrauterine device.

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? A. "You would probably be more successful if you wrapped him in on a warm blanket." B. "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." C. "Let me show you how to calm him down. I've been doing this for many years." D. "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?"

B. "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated fetal heart rate (FHR) changes. What intervention should the nurse perform to manage the changes? A. Assist the client to a supine position. B. Provide supplemental oxygen. C. Discontinue intravenous (IV) fluid. D. Turn the client to her right side.

B. Provide supplemental oxygen. The nurse should provide supplemental oxygen if a client who has been administered combined spinal-epidural analgesia exhibits signs of hypotension and associated FHR changes. The client should be assisted to a semi-Fowler's position; the client should not be kept in a supine position or be turned on her left side. Discontinuing IV fluid will cause dehydration.

Which body system is most vulnerable to infection during the postpartum period? A. Gastrointestinal B. Urinary C. Breasts D. Respiratory

B. Urinary The urinary system must handle an increased workload in the early postpartum period and the renal system is altered by hydronephrosis, a normal change with pregnancy. The hydronephrosis and urinary stasis often lead to urinary tract infections.

A woman states that she still feels exhausted on her second postpartal day. The nurse's best advice for her would be to do which action? A. Avoid getting out of bed for another 2 days. B. Walk with the nurse the length of her room. C. Walk the length of the hallway to regain her strength. D. Avoid elevating her feet when she rests in a chair.

B. Walk with the nurse the length of her room. Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

The nurse is teaching the pregnant woman about nutrition for herself and her baby. Which statement by the woman indicates that the teaching was effective? A. "I can eat any seafood that I like because it contains phosphorus, which is a nutrient that pregnant women need." B. "I will need to take iron supplementation throughout my pregnancy even if I am not anemic." C. "Milk production requires higher levels of calcium; therefore, if I am going to breastfeed, I must take a calcium supplement during pregnancy." D. "Because I am pregnant, I can eat anything I want and not worry about weight gain."

B. "I will need to take iron supplementation throughout my pregnancy even if I am not anemic." Iron is recommended for all pregnant women because it is almost impossible for the pregnant woman to get what is required from diet alone, especially after 20 weeks' gestation when the requirements of the fetus increase. Pregnant women can get many nutrients from seafood including phosphorus, but there are specific recommendations about types of fish to avoid because of the risk of mercury poisoning. Milk production actually requires higher levels of zinc, which can be obtained from a healthy diet. Calcium requirements do not increase above prepregnancy levels during pregnancy because calcium absorption is enhanced during pregnancy. It can be unsafe for the pregnant woman to eat anything she wants and gain too much weight. A woman who gains too much weight during pregnancy is at risk for delivering a macrosomic baby.

A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action? A. Complete bed rest B. Ambulation ad lib C. Bathroom privileges D. Up in chair TID

B. Ambulation ad lib To facilitate the first stage of labor, ambulation and movement will allow better fetal descent and help to speed the labor process. Bed rest will slow or stop the labor process. The client may use the bathroom as needed, but this does not affect labor rate. The client should remain mobile.

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? A. Degree of responsiveness, respiratory rate, fundus location B. Blood pressure, pulse, reports of dizziness C. Height, level of orientation, support systems D. Attachment, lochia color, complete blood cell count

B. Blood pressure, pulse, reports of dizziness Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.

The client at 18 weeks' gestation states, "I feel a fluttering sensation, kind of like gas." The nurse understands that the client is describing what occurrence? A. Lightening B. Quickening C. Placenta previa D. Linea nigra

B. Quickening The fluttering sensation that can be confused with gas is called "quickening." In the 2 weeks leading up to the 20-week mark, she may feel "flutters" that she may confuse with gas. Lightening is the descent of the presenting part of the fetus into the pelvis. Placenta previa is the implantation of the placenta so that it covers part or all of the cervical os. Linea nigra is a hyperpigmented line that appears on the maternal abdomen between the symphysis pubis and top of the fundus.

Which situation should concern the nurse treating a postpartum client within a few days of birth? A. The client would like to watch the nurse give the baby her first bath. B. The client feels empty since she gave birth to the neonate. C. The client is nervous about taking the baby home. D. The client would like the nurse to take her baby to the nursery so she can sleep.

B. The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

A woman you care for in a prenatal clinic tells you that her pregnancy was unplanned and unwanted. At what point in pregnancy does the average woman change her mind about an unwanted pregnancy? A. Around the third month B. When quickening occurs C. After lightening happens D, After the seventh month

B. When quickening occurs Quickening, or feeling the baby move inside the body, is such a dramatic event that it can cause a woman's perceptions about the pregnancy to change.

When preparing a class for a group of pregnant women about nicotine use during pregnancy, the nurse describes the major risks associated with nicotine use including: A. increased risk of spontaneous abortion. B. decreased birth weight in neonates. C. increased risk of stillbirth. D. increased risk of placenta abruptio.

B. decreased birth weight in neonates. The nurse should inform the client that children born of mothers who use nicotine will have a decreased birth weight. Spontaneous abortion is associated with caffeine use. Increased risks of stillbirth and placenta abruptio are associated with mothers addicted to cocaine

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change? A. increased progesterone levels B. decreased intra-abdominal pressure C. decreased bladder pressure D. use of anesthesia during birth

B. decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? A. crowning B. effacement C. dilatation D. molding

B. effacement

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? A. Call the woman's health care provider. B. Assess the woman's vital signs. C. Assess the woman's fundus. D. Begin an IV infusion of Ringer's lactate solution.

C. Assess the woman's fundus. To have a suggested idea of the location of the bleeding, the nurse would need to assess the fundus of the client first.

When discussing infection prevention with a group of prenatal women, which interventions should the nurse emphasize to prevent toxoplasmosis in this population? Select all that apply. A. Apply bug spray to exposed skin every time one goes outside. B. Use condoms regularly when having sex with different partners. C. Cook meat thoroughly before eating. D. Avoid crowds of young children at daycare facilities. E. Have a significant other change the litter box throughout the pregnancy.

C. Cook meat thoroughly before eating. E. Have a significant other change the litter box throughout the pregnancy. Toxoplasmosis, a protozoan infection, is spread most commonly through contact with uncooked meat, although it may also be contracted through handling cat stool in soil or cat litter. Malaria is caused by mosquitos primarily in Africa and South America. Insect repellant helps to prevent malaria. Sexually transmitted diseases can be prevented with condom use. Avoiding crowds of young children at daycare facilities can prevent exposure to CMV.

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? A. Perform the examination as quickly as possible. B. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. C. Wear sterile gloves when assessing the pad and perineum. D. Instruct the client to empty her bladder before the examination.

C. Instruct the client to empty her bladder before the examination. An empty bladder facilitates the examination of the fundus. The client should be in a supine position with her arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? A. Apply cold compresses to the breast. B. Avoid massaging the breast area. C. Perform handwashing before breast-feeding. D. Avoid frequent breast-feeding.

C. Perform handwashing before breast-feeding. As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breast-feeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold, not warm, moist heat to the breast. Gently massaging the affected area of the breast also helps.

Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate? A. She should stop breast-feeding until completing the antibiotic. B. She should supplement feeding with formula until the infection resolves. C. She should continue to breast-feed; mastitis will not infect the neonate. D. She should not use analgesics because they are not compatible with breast-feeding.

C. She should continue to breast-feed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breast-feeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile? A. Travel no more than 120 miles daily. B. Sit in the back seat with feet elevated. C. Stop and walk every 2 hours. D. Limit trips away from home, greater than 200 miles.

C. Stop and walk every 2 hours. Walking increases venous return and reduces the possibility of thrombophlebitis, a risk for pregnant women who sit for extended periods of time. Limiting mileage, sitting in the back with the feet elevated, and limiting trips may help, but they are not enough to prevent phlebitis.

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider? A. coughing and sneezing in the newborn B. short periods of apnea that last 10 seconds in a pink newborn C. a respiratory rate of 15 breaths per minute with nasal flaring D. a respiratory rate of 45 breaths per minute with acrocyanosis

C. a respiratory rate of 15 breaths per minute with nasal flaring Coughing and sneezing are normal reflexes present in the newborn. The respiratory rate of a newborn should be between 30 and 60 breaths per minute. Acrocyanosis can be a normal finding in a newborn and does not indicate respiratory distress. Short periods of apnea that last longer than 15 seconds in the absence of cyanosis can be normal. Nasal flaring is a sign of respiratory distress.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? A. preexisting conditions in the client B. lack of social support from family or friends C. drop in estrogen and progesterone levels after birth D. medications used during labor and birth

C. drop in estrogen and progesterone levels after birth

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? A. every 5 minutes B. every 10 minutes C. every 15 minutes D. every 20 minutes

C. every 15 minutes During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? A. hyperglycemia B. hypertension C. hypovolemia D. hypothyroidism

C. hypovolemia The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.

The nurse is preparing to teach a community class to a group of first-time parents. Which information should the nurse include concerning what the pregnant woman's partner may experience as a normal response? A. feeling distanced from the mother B. no changes, only the mother has changes during pregnancy C. physical symptoms similar to the mother D. desire to be the woman and give birth

C. physical symptoms similar to the mother Couvade syndrome is the occurrence of physical symptoms by the partner, similar to the physical symptoms of the mother. Other emotional symptoms may occur, but they are typically on a person-to-person basis.

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 gm/dL and hematocrit of 42%. Which result should the nurse prioritize? A. Hemoglobin 13 gm/dL and hematocrit 40 percent in a woman who has given birth vaginally B. Hemoglobin 12 gm/dL and hematocrit 38 percent in a woman who has given birth vaginally C. Hemoglobin 11 gm/dL and hematocrit 34 percent in a woman who has given birth by cesarean D.Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean

D. Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 mL of blood lost during the delivery process, the hemoglobin should decrease by 1 gm/dL and the hematocrit by 2 percent. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 mL to 500 mL and for a cesarean delivery approximately 500 mL to 1000 mL. The loss of hemoglobin from 14 gm/dL to 9 gm/dL is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 mL of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.

The nurse is monitoring a client who is recovering from a cesarean delivery with spinal anesthesia. Which sign or symptom should the nurse prioritize if noted on assessment after the administration of morphine sulfate, simethicone, and diphenhydramine? A. Intense itching manifested by scratching B. Abdominal distension and pain C. Difficulty coughing and turning D. Slow respiration, less than 12 breaths per minute

D. Slow respiration, less than 12 breaths per minute Based on the history of medications, this patient may be in respiratory compromise secondary to medications, most likely the morphine sulfate. The CRNA or anesthesiologist needs to be notified ASAP and the nurse should prepare to administer naloxone. If the patient demonstrates intense itching manifested by scratching you would give the ordered diphenhydramine. The simethicone has been ordered for abdominal distension and pain. Difficulty coughing and turning is usually because of pain at the surgical site, and a patient with these symptoms would need support and encouragement from the nurse.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? A. The father's coaching role may be disrupted at times. B. The infant may show increased drowsiness. C. The mother may have continued memory loss postpartum. D. The mother may have difficulty working effectively with contractions.

D. The mother may have difficulty working effectively with contractions. Breathing and relaxation techniques can speed labor. An inability of the woman to do these as a result of pain relief measures can slow labor.

During assessment of the mother during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony? A. firm fundus B. foul-smelling urine C. purulent vaginal drainage D. boggy or relaxed uterus

D. boggy or relaxed uterus A boggy or relaxed uterus is a sign of uterine atony. This can be the result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Foulsmelling urine and purulent drainage are signs of infections but are not related to uterine atony. The firm fundus is normal and is not a sign of uterine atony.

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? A. cephalic B. vertex C. breech D. shoulder

D. shoulder The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.

A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client? A. "The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." B. "It is normal for the discharge to be deep red since it consists of leukocytes, decidual tissue, RBCs, and serous fluid." C. "The discharge at this point in the postpartum period consists of RBCs and leukocytes." D. "This discharge is called lochia, and it consists of leukocytes and decidual tissue."

A. "The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." The nurse should explain to the client that lochia rubra is a deep red mixture of mucus, tissue debris, and blood. Discharge consisting of leukocytes, decidual tissue, RBCs, and serous fluid is called lochia serosa. Discharge consisting of only RBCs and leukocytes is blood. Discharge consisting of leukocytes and decidual tissue is called lochia alba.

After teaching a group of women about the signs of pregnancy, the nurse understands that teaching was successful if the group makes which statement? A. "They will be able to hear the fetal heart rate on auscultation." B. "The woman will have amenorrhea." C. "There will be a positive Hegar's sign." D. "The client will experience quickening."

A. "They will be able to hear the fetal heart rate on auscultation." The positive signs of pregnancy confirm that a fetus is growing in the uterus. Visualizing the fetus by ultrasound, palpating for fetal movements, and hearing a fetal heartbeat are all signs that make the pregnancy a certainty. Amenorrhea is a presumptive sign of pregnancy. Hegar's sign is a probable sign of pregnancy. Quickening is a presumptive sign of pregnancy.

A client presents at the clinic and is interested in obtaining emergency contraception (EC). The nurse explains that EC must be used within 72 hours of unprotected sex to be effective. This is because: A. ECs simply prevent embryo creation and uterine implantation from occurring in the first place. B. ECs can induce an abortion of a recently implanted embryo. C. ECs can help prevent STIs. D. ECs are more effective than regular birth control.

A. ECs simply prevent embryo creation and uterine implantation from occurring in the first place. Explanation: ECs prevent the embryo creation and uterine implantation from occurring. There is no evidence that ECs have any effect on an already-implanted ovum or that they induce abortion. They do not protect against STIs and are less effective than regular birth control.

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do? A. Nothing. Normal time for stage three is 5 to 30 minutes. B. Notify the primary care provider of the problem. C. Increase the IV tocolytic to help in expulsion of the placenta. D. Do a vaginal exam to see if the placenta is stuck in the birth canal.

A. Nothing. Normal time for stage three is 5 to 30 minutes. Following birth, the placenta is spontaneously expelled within 5 to 30 minutes, so there is no problem with this client. No further interventions are needed.

The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse? A. Teach that adequate hydration helps clear the infection quicker. B. Ask primary care provider to prescribe an analgesic. C. Instruct to use a sitz bath while voiding. D. Advise her to take acetaminophen to ease symptoms.

A. Teach that adequate hydration helps clear the infection quicker. Adequate hydration is necessary to dilute the bacterial concentration in the urine and aid in clearing the organisms from the urinary tract. Encourage the woman to drink at least 3000 mL of fluid a day, suggesting she drink one glass per hour. Drinking fluid will make the urine acidic, deterring organism growth. The other choices are also options but address the symptoms and not the root cause. The goal should be to rid the body of the infection, not concentrate on counteracting the results of the infection.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? A. generally within 3 to 6 weeks B. whenever the couple wishes C. generally after 12 weeks D. usually within a couple weeks

A. generally within 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect? A. laceration B. uterine atony C. hematoma D. uterine inversion

A. laceration Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

Part of the initial prenatal assessment should include the client's immunization history. The nurse informs the client to avoid which type of vaccines while she is pregnant? A. live virus vaccine B. inactivated virus vaccine C. bacterial vaccine D. toxoid vaccine

A. live virus vaccine Routine immunizations are not usually indicated during pregnancy. However, no evidence exists of risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. A number of other vaccines have not been adequately studied. Advise pregnant women to avoid live virus vaccines (MMR and varicella) and to avoid becoming pregnant within one month of having received one of these vaccines because of the theoretical risk of transmission to the fetus.

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching? A. moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 B. moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 C. lochia progresses from rubra to serosa to alba within 10 days D. moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5

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

A nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. For which signs and symptoms should the nurse watch to assess for an increased risk of disseminated intravascular coagulation? Select all that apply. A. tachycardia B. bleeding gums C. hypertension D. lochia less than usual E. acute renal failure

A. tachycardia B. bleeding gums E. acute renal failure The nurse should monitor for bleeding gums, tachycardia, and acute renal failure to assess for an increased risk of disseminated intravascular coagulation in the client. The other clinical manifestations of this condition include petechiae, ecchymosis, and uncontrolled bleeding during birth. Hypotension and amount of lochia greater than usual are findings that might suggest a coagulopathy or hypovolemic shock.

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? A. taking-in phase B. taking-hold phase C. letting-go phase D. attachment phase

A. taking-in phase During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. A. women on antithyroid medications B. women on antineoplastic medications C. women using street drugs D. women with more than one infant E. women who had difficulties with breastfeeding in the past

A. women on antithyroid medications B. women on antineoplastic medications C. women using street drugs While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

A pregnant client is diagnosed with syphilis. Which interviewing question would demonstrate respect for the client and therapeutic communication? A. "You should have thought about what diseases you could be exposed to. At least you are HIV negative." B. "I am sure it is frightening to you to be diagnosed with a disease that can affect your baby." C. "I noticed that you seem fidgety. Is there something wrong besides your STI?" D. "Why didn't you use protection when having intercourse with your partner?":

B. "I am sure it is frightening to you to be diagnosed with a disease that can affect your baby."

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: A. "Effleurage is the pattern for cleaning the perineum before birth." B. "Effleurage is light abdominal massage used to displace pain." C. "Effleurage is the effect of a full bladder on fetal descent." D. "Effleurage is massaging the perineum as the fetal enlarges the vaginal opening."

B. "Effleurage is light abdominal massage used to displace pain."

Amanda's menstrual period is two weeks late. She has been feeling tired and has had bouts of nausea in the morning. What classification of pregnancy symptoms is Amanda experiencing? A. Positive B. Presumptive C. Probable D. No classification

B. Presumptive Explanation: The most common presumptive sign of pregnancy is a missed menstrual period, or amenorrhea. Other presumptive signs include nausea, fatigue, swollen, tender breasts, and frequent urination.

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal? A. HR of 90 to 100 body B. temp of 97.9° to 99.7° F C. rounded, symmetrical abdomen D.enlarged labia with pseudomenstruation E. positive Ortolani sign

B. body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

Which strategies is the nurse correct to utilize when attempting to awaken a potentially sleeping fetus? Select all that apply. A. Lay the mother on the left side B. Clap near the mother's abdomen C. Provide the mother a cold beverage D. Place hands on the abdomen to move the fetus E. Use vibroacoustic stimulation

B.Clap near the mother's abdomen C. Provide the mother a cold beverage D. Place hands on the abdomen to move the fetus E. Use vibroacoustic stimulation The nurse is correct to arouse the fetus in a variety of ways. The nurse can use audio stimulation such as clapping near the abdomen or using vibroacoustic stimulation. Providing the mother a cold beverage can also arouse the fetus. Feeling the mother's abdomen for the location of the fetus and moving the body parts can also cause the fetus to move and/or kick. Simply laying the mother on her side may cause a shift in the fetus but is not always enough to arouse the fetus.

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test? A. 12% B. 14% C. 6% D. 8%

C. 6%

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: A. 1 to 2. B. 5 to 9. C. 7 to 10. D. 12 to 15.

C. 7 to 10.

The nurse is teaching a pregnant woman with iron-deficiency anemia about her prescribed iron supplement. The nurse determines that the teaching was successful when the client states that she will take the supplement with: A. fiber-rich foods. B. coffee. C. citrus juice. D. tea.

C. citrus juice. Iron absorption is enhanced when taken with foods high in vitamin C, such as citrus juice. Foods such as coffee, tea, and those high in fiber should be avoided.

On a prenatal visit, a woman in her second trimester has an ultrasound that confirms that the baby is a girl. Which statement by the mother would be troubling to the nurse concerning this finding? A. "We are not naming her yet because ultrasounds have been known to be wrong sometimes." B. "We want to wait on naming her until she is born and we can see her." C. "In our culture, she will not be named until she is 2 weeks old." D. "We don't want to name her because we don't want to get too attached."

D. "We don't want to name her because we don't want to get too attached." Explanation: Having a mother voice concerns about becoming too attached to the fetus she is carrying is concerning. The nurse needs to explore why the mother is reluctant to bond with her fetus. The other responses are all appropriate, taking into personal and cultural beliefs.

A pregnant woman in her 39th week of pregnancy presents to the clinic with a vaginal infection. She tests positive for chlamydia. What would this disease make her infant at risk for? A. chicken pox B. deafness C. neonatal laryngeal papillomas D. blindness

D. blindness A pregnant woman who contracts chlamydia is at increased risk for spontaneous abortion (miscarriage), preterm rupture of membranes, and preterm labor. The postpartum woman is at higher risk for endometritis (Fletcher & Ball, 2006). The fetus can encounter bacteria in the vagina during the birth process. If this happens, the newborn can develop pneumonia or conjunctivitis that can lead to blindness.

A nurse is asked to teach a woman to take her basal body temperature daily to assess the time of ovulation. She can detect her day of ovulation, following ovulation, because her temperature will: A. increase a degree. B. decrease a degree. C. fluctuate a degree daily. D. no longer reflect basal body temperature.

increase a degree. Explanation: The effect of progesterone, released with ovulation, is to increase body temperature.

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement? A. "I can't wait for these stretch marks to disappear after I give birth." B. "I might lose some hair, but it will grow back." C. "This line on my belly will go away over time." D. "My nipples won't be so dark after I give birth."

A. "I can't wait for these stretch marks to disappear after I give birth." Stretch marks gradually fade to silvery lines but do not disappear completely. As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen, face, and nipples gradually fades.

A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave? A. Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications. B. Note in the chart that the woman was not counseled about her asthma. C. Remind her to continue taking asthma medications, to monitor peak flow daily, and to monitor the baby's kicks in the second and third trimesters. D. Schedule an appointment for her to return to discuss her asthma management.

A. Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications. Management of asthma during pregnancy is very important; the nurse must document that the client has the proper ability to manage her asthma for her health and the health of the fetus. Reminding the client to continue taking her prescribed medication and to monitor her peak flow daily is not enough. It is the nurse's responsibility to know that the client knows how to take her medications. Monitoring the baby's kicks in the second and third trimester is an appropriate action. Scheduling a return appointment to discuss asthma management is not appropriate. She could have an asthma attack between the time the nurse sees her and the time of the return appointment. Noting in the chart that the woman was not counseled does not relieve the nurse of their obligation to ensure that the woman knows how to use her inhaler and her peak flow meter.

Which statement is true regarding analgesia versus anesthesia? A. Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area. B. Decreased FHR variability is a common side effect when regional anesthesia is used. C. Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. D. Hypotension is the most common side effect when systemic analgesia is used.

A. Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area. Systemic analgesia should be used with caution near the time of birth because it can cause respiratory depression, in addition to decreased FHR variability. Hypotension is a common side effect of regional anesthesia.

A client presents to the clinic because she thinks she may be pregnant. On examination, the nurse notes that the client's cervix and vaginal mucosa appear a bluish-purple color. The nurse interprets this finding as which sign? A. Chadwick's sign B. Hegar's sign C. Goodell's sign D. Braxton's sign

A. Chadwick's sign Explanation: Common probably signs of pregnancy include a bluish-purple coloration of the vaginal mucosa and cervix (Chadwick's sign), softening of the lower uterine segment or isthmus (Hegar's sign), and softening of the cervix (Goodell's sign). There is no such thing as Braxton's sign; however, there are the Braxton Hicks contractions, which occur throughout the pregnancy preparing the uterus for delivery.

The nurse is monitoring the EFM and notes the following: variable V-shaped decelerations in the FHR lasting about 30 seconds, accelerations of about 5 bpm before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize? A. Help the woman change positions. B. Discontinue supplemental oxygen. C. Position the woman on her side with a pillow under her left hip. D. Start an oxytocic infusion and decrease the rate of IV fluids.

A. Help the woman change positions. Changing to a different position is a first intervention to determine if this will improve the oxygen to the fetus. It may not necessarily mean to elevate the left hip with a pillow. The client could try sitting up and dangling her feet. Supplemental oxygen should be maintained until the mother is stable. Placing the client on her side may increase the work of breathing. Pharmacologic interventions are premature. Lying on the side with the left hip on a pillow is often used to correct postural hypotension related to the vena cava being compressed by the pregnant uterus.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue? A. Hold the baby frequently. B. Speak to his friends who have children. C. Read up on parental care. D. Have the client speak to the primary care provider on her husband's behalf

A. Hold the baby frequently. The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.

A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping? A. Hold the newborn upright with the newborn's head on the mother's shoulder. B. Lay the newborn on its back on its mother's lap. C. Gently rub the newborn's abdomen while the newborn is in a sitting position. D. Lay the newborn on its abdomen in the mother's lap, and gently pat the buttocks.

A. Hold the newborn upright with the newborn's head on the mother's shoulder. The nurse should instruct the mother to hold the newborn upright with the newborn's head on her mother's shoulder. Alternatively, the nurse can also suggest the mother sit with the newborn on her lap with the newborn lying face down. Gently rubbing the newborn's abdomen, giving frequent sips of warm water to the infant and patting the buttocks will not significantly induce burping; burping is induced by the newborn's position. Placing the newborn on the back while trying to elicit burping after feeding may cause choking or aspiration.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate? A. It is a normal skin finding in a newborn. B. It is a sign of a group beta streptocoous skin infection. C. It is an indication that the woman has mistreated her newborn. D. It is a self-limiting virus that does not require treatment.

A. It is a normal skin finding in a newborn. This rash is most likely is erythema toxicum, also known as newborn rash.

The nurse is leading a discussion with a group of pregnant women who have diabetes. The nurse should point out which situation can potentially occur during their pregnancy? A. Polyhydramnios B. Hypotension of pregnancy C. Post-term birth D.Small for gestation age infant

A. Polyhydramnios Polyhydramnios is an increase, or excess, in amniotic fluid and is a pregnancy-related complication associated with diabetes. An infant who is small for gestational age is not associated with a mother who had diabetes prior to pregnancy. Other pregnancy-related complications associated with pregestational DM include hypertensive disorders, preterm birth, and shoulder dystocia

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue? A. The tint is due to jaundice. B. Yellow is the normal color for some newborns. C. The infant needs to be in the sunlight to clear the skin. D. It's a mild reaction to the vitamin K injection.

A. The tint is due to jaundice. Newborns often have a yellow tint to the skin if the newborn develops jaundice. Any newborn developing jaundice needs to be assessed by the health care provider. Jaundice in the first 24 hours is pathologic and must be reported immediately to the health care provider. Jaundice after 2 days is considered physiologic and is due to the liver's inability to adequately process bilirubin which seeps into the tissues, giving the skin a yellowish color. It is not considered normal and does require assessment and intervention. Phototherapy is the recommended treatment of choice, not putting the child in sunlight. It is not a reaction to the vitamin K injection.

The pain of labor is influenced by many factors. What is one of these factors? A. The woman is prepared for labor and birth. B. The woman has a high tolerance for pain. C. The woman has a high threshold for pain. D. The woman has lots of visitors during labor.

A. The woman is prepared for labor and birth. The woman who enters labor with realistic expectations usually copes well and reports a more satisfying labor experience than does a woman who is not as well prepared.

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy? A. acupressure B. acupuncture C. effleurage D. biofeedback

A. acupressure Acupressure is the application of pressure or massage at designated susceptible body points. A common point used for a woman in labor is Co4, which is located between the first finger and thumb on the back of the hand. Women may report their contractions feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point. Acupuncture involves insertion of needles into the same body points. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for birth classes is a classic example of therapeutic touch. Biofeedback is based on the belief people have control and can regulate internal events such as heart rate and pain responses.

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior? A. attachment B. engrossment C. involution D. engorgement

A. attachment When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smoothes the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.

A nurse works at a facility that provides care to clients holding various cultural beliefs. The nurse integrates understanding of the areas recognized by other cultures that are not necessarily acknowledged by the Western culture. Which area would the nurse need to incorporate into the plans of care? A. balance of hot and cold B. introducing the infant to the rest of the family C. allowing family members at the birth D. expectations of what the new mother should be doing

A. balance of hot and cold Two areas that are significantly different from Western culture involve beliefs about the balance of hot and cold and confinement after birth. Postpartum nurses need to understand these diverse cultural beliefs and provide creative strategies for encouraging hygiene, exercise, and balanced nutrition, while remaining respectful of the cultural significance of these practices.

A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea? A. burning on urination B. dry, hacking cough C. diffuse skin rash D. painless chancre

A. burning on urination Explanation: Burning on urination may be a symptom of gonorrhea or urinary tract infection. A dry, hacking cough is a sign of a respiratory infection, not gonorrhea. A diffuse rash may indicate secondary stage syphilis. A painless chancre is the hallmark of primary syphilis. It appears wherever the organisms enter the body, such as on the genitalia, anus, or lips.

A nurse is required to assess a client reporting unusual vaginal discharge for bacterial vaginosis. For which classic manifestation of this condition should the nurse assess? A. characteristic "stale fish" odor B. heavy yellow discharge C. dysfunctional uterine bleeding D. erythema in the vulvovaginal area

A. characteristic "stale fish" odor Explanation: Symptoms of bacterial vaginosis include a characteristic "stale fish" odor and thin, white homogeneous vaginal discharge, not heavy yellow discharge. Dysfunctional uterine bleeding is a sign of chlamydia, not bacterial vaginosis. Erythema in the vulvovaginal area is a symptom of vulvovaginal candidiasis, not bacterial vaginosis.

The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone? A. estrogen B. progesterone C. hCG D. prolactin

A. estrogen The endocrine system rapidly undergoes several changes after birth. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. hCG and prolactin are not associated with postpartum diuresis

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn? A. lack of subcutaneous fat B. continual kicking C. continual crying D. constriction of blood vessels

A. lack of subcutaneous fat Insulation, an efficient means of conserving heat in adults, is not as effective in newborns because they have little subcutaneous fat to provide insulation. Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. Brown fat, a special tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. Other ways newborns are able to increase their metabolic rate and produce more heat include kicking and crying.

The nurse is teaching a pregnant woman about breast feeding. The nurse determines that the teaching was successful when the woman identifies which hormone as being released when the newborn sucks at the breast? A. oxytocin B. follicle stimulating hormone C. antidiuretic hormone D. cortisol

A. oxytocin Explanation: Oxytocin is responsible for milk ejection during breast-feeding. Its secretion is stimulated by stimulation of the breasts via sucking or touching. Secretion of follicle-stimulating hormone is inhibited during pregnancy. The secretion of antidiuretic hormone has no effect on breast-feeding. Cortisol secretion regulates carbohydrate and protein metabolism and is helpful in times of stress.

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production? A. prolactin B. estrogen C. oxytocin D. progesterone

A. prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage? A. uterine atony B. hemorrhoid C. diuresis D. iron deficiency

A. uterine atony Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during postpartum, diuresis causes weight loss during the first postpartal week, whereas iron deficiency causes anemia in the puerperium.

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? A. "It takes a while to get your body back to its normal function after having a baby." B. "You might try using a water-soluble lubricant to ease the discomfort." C. "This is entirely normal, and many women go through it. It just takes time." D. "Try doing Kegel exercises to get your pelvic muscles back in shape."

B. "You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? A. Braxton Hicks contractions get closer together with activity. B. Braxton Hicks contractions usually decrease in intensity with walking. C. Braxton Hicks contractions do not last long enough to be true labor. D. Braxton Hicks contractions cause "ripening" of the cervix.

B. Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.

The nurse is teaching a non-English speaking primigravida about the most common type of fetal presentation. Which presentation will the nurse prepare? A. Breech presentation using a picture of the type B. Cephalic presentation using preprinted materials in her language C. Occiput presentation using a PowerPoint presentation D. Footling presentation drawing a hand-prepared diagram

B. Cephalic presentation using preprinted materials in her language The most common presentation type is the cephalic presentation, and it is most appropriate to highlight the information using preprinted materials in her own language. Both portions of this answer are best. With pictures, the nurse can communicate on a common level and then the woman has the opportunity to review as needed. The breech and cephalic presentations are not the most common presentations. The footling is not a presentation.

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply. A. Inverted nipples following breastfeeding B. Fundus one fingerbreadth below the umbilicus C. Hypoactive bowel sounds D. Urination of 100 mL every 4 hours E. Moderate saturation of peripad every 3 hours

B. Fundus one fingerbreadth below the umbilicus E. Moderate saturation of peripad every 3 hours A fundus should be one fingerbreadth below the umbilicus at 24-hours postpartum, and moderate saturation of two-thirds of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypoactive bowel sounds also require assessment more frequently than routinely ordered, and urination of100 mL every 4 hours is inadequate given the occurrence of diuresis.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. A. Give newborns water and other foods to balance nutritional needs. B. Help the mother initiate breastfeeding within 30 minutes of birth. C. Encourage breastfeeding of the newborn infant on demand. D. Provide breastfeeding newborns with pacifiers. E. Place baby in uninterrupted skin-to-skin contact with the mother.

B. Help the mother initiate breastfeeding within 30 minutes of birth. C. Encourage breastfeeding of the newborn infant on demand. E. Place baby in uninterrupted skin-to-skin contact with the mother. The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response? A. Fencing B. Moro C. Tonic neck D. Rooting

B. Moro The Moro reflex is also known as the startle reflex. When the infant is startled, they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments? A. Breasts B. Perineum C. Lower extremities D. Respiratory status

B. Perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.

The nurse is teaching a young couple, who desire to start their family, the various methods for determining fertility. After discovering the woman regulary travels internationally for work, deals with a lot of job anxiety and frequently uses an electric blanket at home, the nurse will discourage the use of which method? A. calendar method B. basal body temperature method C.cervical mucus method D.symptothermal method

B. basal body temperature method Explanation: BBT is a method where the body temperature should be checked first thing in the morning and recorded, immediately after waking and before getting out of bed. It is important for the patient to maintain a normal bedtime routine. Use of the electric blanket, stress, and anxiety can cause a false elevation in the BBT. The calendar method would depend upon her schedule. Cervical mucus and symptothermal methodology would be viable options.

A primiparous mother gave birth to an 8 lb 12 oz (4 kg) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? A. formula feeding B. cephalohematoma C. female gender D. hepatitis A vaccine E. Rh positive blood type

B. cephalohematoma Risk factors for the development of jaundice include bruising as seen in a cephalohematoma, male gender and being breastfed. Blood type incompatabliity is only an issue if the infant's blood type differs from the mother and the maternal blood type is not stated. Administering hepatitis A vaccine does not increase the risk of jaundice.

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color? A. bluish white B. creamy yellow C. milky white D. gray liquid

B. creamy yellow If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? A. infection B. dehydration C. change in the temperature from the birth room D. fluid volume overload

B. dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? A. hemorrhage B. infection C. depression D. pulmonary emboli

B. infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? A. shoulders B. occiput C. brow D. buttocks

B. occiput With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

Which finding would alert the nurse to suspect that a client has a yeast infection? A. changes in skin color B. vulvar burning and itching C. lymphadenopathy D. acidic vaginal secretions

B. vulvar burning and itching Explanation: The primary symptom of a yeast infection is burning and itching on the vulva or in the vagina. Acidic vaginal secretions are not the primary symptoms of a yeast infection. Skin changes and lymphadenopathy may occur in the breast and require a follow up for breast exam; however, these are not associated with yeast infections.

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: A. "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." B. "It is flat and narrow, making it extremely difficult for the neonate to pass through." C. "It is rounded in shape and allows ample room for the neonate to fit through the passageway." D. "It is elongated, the width is roomy, but the length is narrow."

C. "It is rounded in shape and allows ample room for the neonate to fit through the passageway." The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid pelvis inlet allows the fetus room to pass through the dimensions of the bony passageway.

A client reports occasional headaches. She wants to know what she can take to alleviate the discomfort. What would be the best response by the nurse? A. "You don't want to harm the baby by taking medications now, do you?" B. "Wait until you reach your third trimester. You can take something to relieve headaches then." C. "The safest medication to take for your headaches during your pregnancy would be acetaminophen." D. "The safest medication to take for your headaches during your pregnancy would be ibuprofen."

C. "The safest medication to take for your headaches during your pregnancy would be acetaminophen."

A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the best response if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration? A. "Your baby is fine, just learning how to breath." B. "Let's put a blanket around the baby; the baby is cold." C. "Your baby is having a little trouble breathing. I'll let the RN know." D. "Your baby is too warm. Let's take the blanket off."

C. "Your baby is having a little trouble breathing. I'll let the RN know." The assessment findings discussed are signs of respiratory distress. An infant with a respiratory rate of greater than 60 with noise requires further assessment. This does not indicate the infant is either too cold or too warm, so using or not using a blanket would not be a factor in this scenario.

A client is 33 weeks pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled? A. 136 mg/dL B. 45 mg/dL C. 85 mg/dL D. 120 mg/dL

C. 85 mg/dL Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dL. A fasting blood glucose level of 45 g/dL is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dL is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dL in a pregnant client indicates hyperglycemia.

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax? A. Anxiety will increase blood pressure, increasing risk with an epidural. B. Decreased anxiety will increase trust in the nurse. C. Anxiety can slow down labor and decrease oxygen to the fetus. D. Increased anxiety will increase the risk for needing anesthesia.

C. Anxiety can slow down labor and decrease oxygen to the fetus. Out of control anxiety can decrease the oxygen of the mother by increasing her respiratory rate and increasing the demand on her body, and can have a negative impact on the fetus by decreasing the amount of oxygen reaching the fetus. Encourage control of the anxiety. Anxiety will not negatively affect the action of the epidural or the need for anesthesia. Trust in the nurse is not determined by the amount of anxiety the client experiences.

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? A. Tell the woman to stay home until her membranes rupture. B. Emphasize that food and fluid should stop or be light. C. Ask the woman to describe why she believes that she is in labor. D. Arrange for the woman to come to the hospital for labor evaluation.

C. Ask the woman to describe why she believes that she is in labor. The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as the client may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not the client is in labor. The client may be in false labor, and more information should be obtained before the client is brought to the hospital.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? A. Heart Rate B. Respiratory Rate C. Blood Pressure D. Temperature

C. Blood Pressure The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).

A pregnant client in her third trimester, lying supine on the examination table, suddently grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize? A. Cerebral arteries are growing congested with blood. B. The uterus requires more blood in a supine position. C. Blood is trapped in the vena cava in a supine position. D. Sympathetic nerve responses cause dyspnea when a woman lies supine.

C. Blood is trapped in the vena cava in a supine position. Explanation: Supine hypotension syndrome, or an interference with blood return to the heart, occurs when the weight of the fetus rests on the vena cava. Cerebral arteries should not be affected. Mean arterial pressure is high enough to maintain perfusion of the uterus in any orientation. The sympathetic nervous system will not be affected by the supine position.

Which disease process would the nurse screen for under potential genetic disorders? A. Tuberculosis B. Rheumatic fever C. Cystic fibrosis D. Asthma

C. Cystic fibrosis Screening of genetically linked disorders is important when obtaining a family history. Cystic fibrosis is a genetically linked disorder. Tuberculosis is an infectious disorder. Rheumatic fever stems from a streptococcus infection. Asthma is a hypersensitivity typically from an environmental allergy.

The nurse is caring for a client experiencing pruritus secondary to opioid medication administration during labor. When reviewing the medication administration record, which medication would the nurse offer the client? A. Meperidine B. Naloxone C. Diphenhydramine D. Nalbuphine

C. Diphenhydramine Diphenhydramine is an antihistamine which would be helpful to the client experiencing pruritus as a side effect of opioid medication administration. Meperidine is another opioid analgesic. Both naloxone and nalbuphine are opioid antagonists.

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using? A. Massage B. Abdominal imagery C. Effleurage D. Pain pathway blockage

C. Effleurage Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? A. Fetal station B. Fetal attitude C. Fetal position D. Fetal size

C. Fetal position When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.

Which is the most important nursing assessment of the mother during the fourth stage of labor? A. The mother's psyche B. Blood pressure C. Hemorrhage D. Heart rate

C. Hemorrhage During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? A.Instill 0.5% ophthalmic silver nitrate. B. Instill 0.5% ophthalmic tetracycline. C. Instill 0.5% ophthalmic erythromycin. D. Watch for signs of eye irritation.

C. Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.

The head nurse of the newborn nursery is teaching new employees ways to reduce the transmission of infection in the nursery. What information would be included in this session? A. Newborns should be kept in the nursery except for feedings. B. Scrub your hands for 3 minutes before entering the nursery if you are wearing artificial nails. C. Keep all of the newborn's belongings together in the bassinet. D.It is acceptable to share diapers and wipes between newborns but nothing else.

C. Keep all of the newborn's belongings together in the bassinet. By keeping all the newborn's belongings in the bassinet and not sharing items, the risk of cross-contamination is greatly reduced. Rooming-in, not staying in the nursery, also reduces the likelihood of cross-contamination. Artificial nails are shown to increase infection transmission and should not be worn.

The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information? A. Report any signs of possible urinary tract infection B. Long term therapy goals C. Maintain a daily blood glucose log D. Plan daily menus with dietitian

C. Maintain a daily blood glucose log Control of the blood glucose throughout the pregnancy is the primary goal to help decrease potential complications to both the mother and fetus. The mother should keep a daily log of her blood glucose levels and bring this log to each visit for the nurse to evaluate. The other choices of reporting possible signs of a UTI and working with a dietitian to plan menus would also be important but would follow stressing the blood glucose control. It would be inappropriate to discuss long-term goals at this time. This would be handled at a later time and would depend on the mother's situation.

Which recommendation would the nurse give to a pregnant client with a sexually transmitted infection who is at risk for transmitting the infection? A. Pat or blot the skin dry. B. Have regular cancer screening examinations. C. Participate in early prenatal care. D. Take tub baths regularly.

C. Participate in early prenatal care. Explanation: The nurse should recommend that a pregnant client with a sexually transmitted infection who is at risk of infection transmission receive early prenatal care because some STIs can be transmitted during birth. Patting or blotting the skin dry is helpful in reducing friction and itch-scratch-itch cycle. The nurse should recommend clients infected with carcinogenic viruses to have regular cancer screening examinations to facilitate early diagnosis and optimistic prognosis. Taking tub baths regularly would have no effect on infection transmission.

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex? A. Moro B. Tonic neck C. Rooting D. Sucking

C. Rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle) reflex are total body reflexes and assess neurologic function in the newborn.

A client in her third trimester of pregnancy wishes to formula feed her baby. What instruction should the nurse provide? A. Mix one scoop of powder with an ounce of water. B. Feed the infant every 8 hours. C. Serve the formula at room temperature. D. Refrigerate any leftover formula.

C. Serve the formula at room temperature. The nurse should instruct the client to serve the formula to her infant at room temperature. The nurse should instruct the client to follow the directions on the package when mixing the powder because different formulas may have different instructions. The infant should be fed every 3 to 4 hours, not every 8 hours. The nurse should specifically instruct the client to avoid refrigerating the formula for subsequent feedings. Any leftover formula should be discarded.

A nurse is providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching? A. Her baby is at increased risk for neonatal diabetes mellitus. B. Her baby is at increased risk for type 1 diabetes mellitus. C. She is at increased risk for type 1 diabetes mellitus after her baby is born. D. She is at increased risk for type 2 diabetes mellitus after her baby is born.

C. She is at increased risk for type 2 diabetes mellitus after her baby is born.

A client in her third trimester reports to the nurse shortness of breath when sleeping. The nurse informs the client that this is normal and occurs because the growing fetus puts pressure on the diaphragm. Which measure should the nurse suggest to help alleviate this problem? A. Avoid overeating. B. Lie on a firmer mattress. C. Use extra pillows. D. Avoid spicy food.

C. Use extra pillows. The nurse should instruct the client to use extra pillows at night to keep her more upright. The nurse can instruct the client to use a firmer mattress if the client is experiencing backache. The nurse can ask the client to avoid overeating and ingesting spicy food in case the client is experiencing heartburn.

A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client? A. Actively stimulate the infant to cry. B. Offer blow-by oxygen. C. Wrap the infant in a blanket and hand to the mother for bonding. D. Place the infant in a warmer bed and heat the newborn up.

C. Wrap the infant in a blanket and hand to the mother for bonding. Apgar scores of 7-10 at 5 minutes of age indicate a newborn is adapting well to extrauterine life and can be safely placed with the mother. A 5-minute Apgar score of 4-6 would mean that the newborn might have respiratory distress and need oxygen or requires more vigorous stimulation. Hypothermia can also cause distress and lower the Apgar score.

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: A. inspect the perineum for lacerations. B. increase the flow of an IV. C. assess and massage the fundus. D. call the primary care provider or the nurse-midwife.

C. assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? A. respiratory rate of 50 breaths/minute B. acrocyanosis C. asymmetrical chest movement D. short periods of apnea (less than 15 seconds)

C. asymmetrical chest movement Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.

A nurse at the health care facility assesses a client in the 20th week of gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client? A. at the top of the symphysis pubis B. halfway between the symphysis pubis and the umbilicus C. at the level of the umbilicus D. at the xiphoid process

C. at the level of the umbilicus In the 20th week of gestation, the nurse should expect to find the fundus at the level of the umbilicus. The nurse should palpate at the top of the symphysis pubis between 10 to 12 weeks' gestation. At 16 weeks' gestation, the fundus should reach halfway between the symphysis pubis and the umbilicus. With a full-term pregnancy, the fundus should reach the xiphoid process.

A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which location? A. symphysis pubis B. between the symphysis and umbilicus C. at the umbilicus D. just below the ensiform cartilage

C. at the umbilicus At 20 weeks, the fundus can be palpated at the umbilicus. A fundus of 12 weeks' gestation is palpated at the symphysis pubis. At 16 weeks' gestation, the fundus is midway between the symphysis pubis and umbilicus. At 36 weeks' gestation, the fundus can be palpated just below the ensiform cartilage.

During pregnancy a woman has many psychological adaptations that must be made. The nurse must remember that the baby's father is also experiencing the pregnancy and has adaptations that must be made. Some fathers actually have symptoms of the pregnancy along with the mothers. What is this called? A. pseudo pregnancy B. pregnancy syndrome C. couvade syndrome D. cretinism

C. couvade syndrome Explanation: Some fathers actually experience some of the physical symptoms of pregnancy, such as nausea and vomiting, along with their partner. This phenomenon is called couvade syndrome.

A 28-year-old primigravida client with diabetes mellitus, in her first trimester, comes to the health care clinic for a routine visit. The client reports frequent episodes of sweating, giddiness, and confusion. What should the nurse tell the client about these experiences? A. tissue sensitivity to insulin increases as pregnancy advances B. use of insulin needs to be reduced as pregnancy advances C. increased secretion of insulin occurs in the first trimester D. insulin resistance becomes minimal in the latter half of the pregnancy

C. increased secretion of insulin occurs in the first trimester Explanation: Increased secretion of insulin in the maternal body in the first trimester is due to the rise in serum levels of estrogen, progesterone, and other hormones. During the second half of pregnancy, tissue sensitivity to insulin progressively decreases, producing hyperglycemia and hyperinsulinemia. Use of insulin needs to be increased not reduced as pregnancy advances. Insulin resistance becomes maximal not minimal in the latter half of the pregnancy.

A pregnant woman in her second trimester comes to the prenatal clinic for a routine visit. She reports that she has a new kitten. The nurse would have the woman evaluated for which infection? A. parvovirus B19 B. cytomegalovirus C. toxoplasmosis D. herpes simplex virus

C. toxoplasmosis Toxoplasmosis is transferred by hand to mouth after touching cat feces while changing the litter box or through gardening in contaminated soil. Cytomegalovirus is transmitted via sexual contract, blood transfusions, kissing, and contact with children in daycare centers. Parvovirus B19 is a common self-limiting benign childhood virus that causes fifth disease. A pregnant woman may transmit the virus transplacentally to her fetus if she is exposed to an infected child. Herpesvirus infection occurs by direct contact of the skin or mucous membranes with an active lesion through kissing, sexual contact, or routine skin-to-skin contact.

A client desires protection from unwanted pregnancies. However, the client does not enjoy sex when her partner wears a male condom. Also, the client experiences breast tenderness, headache, and nausea after taking oral contraceptives. Which method would be the most likely choice for the couple to help them enhance their sexual experience as well as prevent any side effects? A. natural membrane condom B. polyurethane condom C. transdermal contraceptive D. ethinyl estradiol

C. transdermal contraceptive Explanation: Application of transdermal contraceptive patches to the skin would most likely be the option for this couple. These patches will not hamper the sexual experience nor cause side effects such as those caused by oral contraceptives. Natural membrane and polyurethane condoms are forms of male condoms, which the client does not like. Ethinyl estradiol is a combined oral contraceptive, which would most likely cause the client to experience breast tenderness, headache, and nausea.

A pregnant client in her second trimester informs the nurse that she needs to travel by air the following week. Which precaution should the nurse instruct the client to take during the flight? A. Wear a padded bra. B. Wear low-heeled shoes. C. Wear support hose. D. Wear cotton clothes.

C. wear support hose The nurse should instruct the client to wear support hose while traveling by air. The nurse should also instruct the client to periodically exercise the legs and ankles, and walk in the aisles if possible. Wearing low-heeled shoes, cotton clothes, or a padded bra will have no effect on the client during the flight.

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? A. +4 B. +2 C. 0 D. -2

D. -2 When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A fetus at 0 (zero) station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.

What is the most effective way for a nurse to assess a woman's usual food intake during her pregnancy? A. Assess a list she makes describing a good diet. B. Ask her to describe her total intake for a week. C. Assess her skin for hydration and color. D. Ask her to describe her intake for the last 24 hours.

D. Ask her to describe her intake for the last 24 hours.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? A. Assess maternal blood pressure. B. Assess for constipation. C. Assess for dry mouth. D. Assess fetal heart rate.

D. Assess fetal heart rate. After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier with symptoms including assessing heart rate and variability. After birth, there may be a decrease in alertness. Maternal factors of a decreased blood pressure, constipation and dry month are of a lower priority.

If a woman is 3 months pregnant, which of the following findings related to breast changes would you expect to assess? A. Slack, soft breast tissue B. Deeply fissured nipples C. Enlarged lymph nodes D. Darkened breast areolae

D. Darkened breast areolae

A client in her second trimester of pregnancy has developed varicose veins and experiences leg cramps. Which suggestion would be most appropriate? A. Perform aerobic exercises. B. Increase intake of folic acid. C. Increase intake of calcium. D. Elevate legs while sitting.

D. Elevate legs while sitting. The nurse should encourage the client to elevate her legs while sitting; this will prevent pooling and engorgement of veins in the lower extremities. Aerobic exercises do not help in preventing varicose veins. Folic acid intake is recommended in the first trimester to prevent congenital abnormalities. Increasing the intake of calcium helps in strengthening bones.

A laboring mother requests that she be allowed to participate in kangaroo care following delivery. The nurse understands that this involves what action? A. Wrapping the newborn in a towel and placing it on the mother's abdomen. B. Allowing the mother to cut the cord of the newborn. C. Laying the newborn in a radiant warmer for 30 minutes followed by the mother holding the newborn for 30 minutes. D. Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket.

D. Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket. Kangaroo care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding.

A woman visits the family planning clinic to request a prescription for birth control pills. Which factor would indicate that an ovulation suppressant would not be the best contraceptive method for her? A. She is 30 years old. B. She has irregular menstrual cycles. C. She has a history of allergy to foreign protein. D. She has a family history of thromboembolism.

D. She has a family history of thromboembolism. Explanation: The estrogen content of birth control pills may lead to increased blood clotting, leading to an increased incidence of thromboembolism. Women who already are prone to this should not increase their risk further.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? A. The flow contains large clots. B. The flow is over 500 mL. C. Her uterus is soft to your touch. D. The color of the flow is red.

D. The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? A. cracking of the nipple B. improper positioning of infant C. inadequate secretion of prolactin D. inability of infant to empty breasts

D. inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

During the second stage of labor, a woman is generally: A. very aware of activities immediately around her. B. anxious to have people around her. C. no longer in need of a support person. D. turning inward to concentrate on body sensations.

D. turning inward to concentrate on body sensations. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.

A nurse is instructing a client on birth control methods. The client asks about the cervical mucus method. When should the nurse tell the client she is fertile in relation to her mucus? A. when it is thin, watery, and copious B. when it is thick C. Cervical mucus is not a reliable indicator. D. when it does not stretch

when it is thin, watery, and copious Explanation: The cervical mucus method relies on the changes that occur naturally with ovulation. Before ovulation, cervical mucus is thick and does not stretch when pulled. With ovulation, the mucus becomes thin, copious, watery, transparent, and stretchy.

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? A. Difficulty breathing B. Staggering gait C. Decreased level of consciousness D. Intense pain

A. Difficulty breathing Total spinal blockade occurs when an inadvertent injection of a local anesthetic is placed into the intrathecal or epidural space. The resulting effect is that the anesthetic travels too high in the body causing paralysis of the respiratory muscles. Difficulty breathing is a sign. A decreased level of consciousness will occur later. A staggering gait or intense pain is not a primary symptom.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. A. vital signs of mother B. newborn's vital signs C. pain level D. head-to-toe assessment E. head-to-toe assessment of newborn

A. vital signs of mother C. pain level D. head-to-toe assessment Postpartum assessment of the mother usually includes vital signs, pain level, and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery.