Maternity Exam #1

In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the first hours after birth

50-60 mg/dL In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dL during the first several hours after birth. A blood sugar level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. This infant can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life, the blood glucose levels should be approximately 60 to 70 mg/dL.

When caring for a newborn, the nurse must be alert for signs of cold stress, including: A) Decreased activity level B) Increased respiratory rate C) Hyperglycemia D) Shivering

B) Increased respiratory rate Infants experiencing cold stress would have an increased activity level. An increased respiratory rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

At what stage of pregnancy is it common to observe hemodilutional anemia? A. First trimester B. Second trimester C. Third trimester D. At any stage with proper supplementation

C. Third trimester

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of postpartum hemorrhage in this woman is: A. Retained placental fragments B. Unrepaired vaginal lacerations C. Uterine atony D. Puerperal infection

C. Uterine atony A. Incorrect: Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman B. Incorrect: Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth C. Correct: This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony D. Incorrect: Puerperal infection can cause subinvolution and subsequent bleeding, but it typically would be detected after 24 hours postpartum.

When weighing a newborn, the nurse should: A) Leave its diaper on for comfort B) Place a sterile scale paper on the scale for infection control C) Keep hand on the newborn's abdomen for safety D) Weigh the newborn at the same time each day for accuracy

D) Weigh the newborn at the same time each day for accuracy The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights

The nurse is researching the relationship between estrogen and lactation. The nurse discovers that the lactating client is more susceptible to: A. Hemorrhage B. Infection C. Diastasis recti D. Dyspareunia

D. Dyspareunia Lactation puts breastfeeding women in a hypoestrogenic state due to ovarian suppression, which could lead to dyspareunia (painful intercourse). There is no correlation between lactation and hemorrhage, infection, or diastasis recti.

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? A. Pain level 5 on scale of 0 to 10 B. Saturated pad over a 2-hour period C. Urinary output of 500 mL in one voiding D. Uterine fundus 2 cm above the umbilicus

D. Uterine fundus 2 cm above the umbilicus By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum patient

During the immediate postpartum period, saturation of one pad within 2 hours is considered ____________________ blood loss.

Heavy

A pregnant woman presents to her healthcare provider for her first prenatal visit at 6 weeks gestation. As part of her baseline labs, a complete blood count (CBC) is performed. Her hemoglobin (Hgb) level is measured at 12 g/dL. At her 20-week prenatal visit, her CBC is repeated, and her Hgb level is now 10.5 g/dL. Which phenomenon best explains this change?

Hemodilutional anemia. During pregnancy, the plasma volume increases significantly, almost doubling by the 28th week. This increased plasma volume dilutes the concentration of red blood cells, leading to lower Hgb levels without actual loss of red blood cells. Thus, the decrease in Hgb from 12 g/dL to 10.5 g/dL is consistent with hemodilutional anemia

How can a mother prevent engorgement?

Wear a tight sports bra 24/7 for the first 2 weeks

What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? A) Apical heart rate of 90 beats/min, slightly irregular, when awake and active B) Acrocyanosis C) Harlequin color sign D) Weight loss representing 5% of the newborn's birth weight

A) Apical heart rate of 90 beats/min, slightly irregular, when awake and active The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.

Which question from a postpartum client indicates a need for further teaching about managing afterpains? A. "Can I get an ice pack for my belly to help with these cramps?" B. "Should I have my mom bring me a lysine supplement? She says it might help." C. "The baby's due to nurse in about an hour. Can I have some ibuprofen?" D. "I guess we can expect this to be worse after having twins that it was with my singleton, right?"

A. "Can I get an ice pack for my belly to help with these cramps?" Application of heat is helpful in managing afterpains. Ice may make them feel worse. Lysine supplements and taking an analgesic an hour before feeding are helpful. Increased discomfort with afterpains can be expected following overdistention of the uterus, such as multiple gestation

The nurse prepares to administer vitamin K to a newborn. Which action by the nurse is correct? A. Administers on the vastus lateralis muscle B. Administers vitamin K orally C. Administers vitamin K 24 hours after birth D. Administers the medication before mother-baby interaction

A. Administers on the vastus lateralis muscle Because almost all newborns can be predicted to have this diminished blood coagulation ability, vitamin K is usually administered intramuscularly into the lateral anterior thigh, or the vastus lateralis muscle, the preferred site for all injections in newborns., immediately after birth. If the parents object to an injection, vitamin K can be administered orally, although it is not as effective. Oral vitamin K is less effective than IM vitamin K in preventing vitamin K deficiency bleeding. Vitamin K must be administered routinely to all newborns within the first six hours after birth and following initial stabilization and appropriate maternal-newborn interactions.

The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include?Select all that apply A. Apply ice to perineum for first 12 hours B. Take sitz baths at temperature of 107.6°-111.2°F (42-44°C) C. Use witch hazel compresses on rectal areas for hemorrhoids D. Take ibuprofen for pain E. Apply topical anesthetics to perineal area F. Avoid sexual intercourse until episiotomy has healed

A. Apply ice to perineum for first 12 hours C. Use witch hazel compresses on rectal areas for hemorrhoids D. Take ibuprofen for pain E. Apply topical anesthetics to perineal area F. Avoid sexual intercourse until episiotomy has healed A., C., D., E., & F. Correct: Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Chemical ice packs or clean gloves filled with ice may be used during the first 12 hours after a vaginal birth. Witch hazel contains chemicals called tannins. When applied directly to the skin, witch hazel might help reduce swelling and help repair broken skin. Analgesics such as acetaminophen and nonsteroidal anti inflammatory drugs (NSAIDs) such as ibuprofen frequently are prescribed to provide relief for mild to moderate discomfort. Topical anesthetic may be used as needed to decrease surface discomfort and allow more comfortable ambulation. Sexual intercourse prior to healing of the episiotomy may contribute to further perineal damage B. Incorrect: This temperature is too hot and can damage the injured tissue. The sitz bath should be at a temperature of 100-104°F (38-40°C).​)

What is the nurse's chief concern when a mother who delivered 2 hours ago has a blood pressure change from 112/70 to 142/94? A. Developing preeclampsia B. Fluid overload C. Puerperal hypertension D. Worsening systolic heart murmur

A. Developing preeclampsia This is a significant increase in the blood pressure, and the most dangerous complication at this point is the occurrence of preeclampsia. In a postpartum woman, diuresis should control the fluid volume and hypertension should not develop. A heart murmur would more likely cause symptoms of heart failure

Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level? A. Distended bladder B. Normal involution C. Been lying on her right side too long D. Stretched ligaments that are unable to support the uterus

A. Distended bladder The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the patient should not alter uterine position. The problem is a full bladder displacing the uterus

If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take? A. Document the finding. B. Inform the health care provider. C. Begin antibiotic therapy immediately. D. Have the laboratory draw blood for reanalysis

A. Document the finding. An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. There is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated

A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother-baby unit 2 hours after the client gave vaginal birth to the neonate. Which of the following information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit? A. Firm fundus when gentle massage is used B. Evidence of bonding well with the neonate C. Labor that lasted 12 hours with a 1-hour second stage D. Temperature of 99°F (37.4°C) and pulse rate of 80 bpm

A. Firm fundus when gentle massage is used The priority assessment is that the client has a firm fundus when gentle massage is used. This indicates that the client's fundus may be soft or "boggy" when it is not massaged. The receiving nurse should assess the client's fundus soon after admission and continue to monitor the client's fundus, lochia, and pulse rate. Postpartum hemorrhage is associated with uterine atony. Maternal-infant bonding is a process that usually starts on day 2 and ends at week 1. A 12-hour labor is normal. The temperature and pulse are within normal limits.

Which of the following are functions of the placenta in pregnancy? SATA: A. Gas exchange B. Nutrient transfer C. Waste removal D. Allows room for symmetric growth of the fetus E. Thermoregulation for the mother and fetus F. Ab IgG transfer at the end of pregnancy G. Hormone production

A. Gas exchange B. Nutrient transfer C. Waste removal F. Ab IgG transfer at the end of pregnancy G. Hormone production D and E are incorrect because those are functions of the amniotic fluid in the amniotic sac, not functions of the placenta

Which patient would be most likely to have severe afterbirth pains and request a narcotic analgesic? A. Gravida 5, para 5 B. Primipara who delivered a 7-lb boy C. Patient who is bottle feeding her first child D. Patient who is breastfeeding her second child

A. Gravida 5, para 5 The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems that will cause her discomfort. The patient who is nursing her second child will have more afterpains than her first pregnancy; however, they will not be as severe as the grand multiparous patient

Regarding neurologic conditions, which of the following is true of headaches during the postpartum period? A. Headaches are the most common neurologic symptoms demonstrated by postpartum clients B. Spinal anesthesia is not associated with a risk for headache C. Migraine headaches are more common during pregnancy D. Hypertension is not associated with headaches

A. Headaches are the most common neurologic symptoms demonstrated by postpartum clients It is true that headaches are the most common neurologic symptoms demonstrated by postpartum clients. Spinal anesthesia is associated with a risk for headache; migraine headaches are not more common during pregnancy; and hypertension is associated with headaches.

Many new mothers experience some type of nipple pain during the first weeks of initiating breastfeeding. Should this pain be severe or persistent, it may discourage or inhibit breastfeeding altogether. The nurse should be aware of a variety of factors that may contribute to nipple pain. These include (choose all that apply): A. Improper feeding position B. Large for gestational age infant C. Fair skin D. Progesterone deficiency E. Flat or retracted nipples

A. Improper feeding position C. Fair skin E. Flat or retracted nipples

Which of the following laboratory findings would most likely be considered normal in the immediate postpartum period? A. Increased white blood cell (WBC) count B. Decreased erythrocyte sedimentation rate (ESR) C. Decreased hematocrit D. Increased platelet (PLT) count

A. Increased white blood cell (WBC) count Increased white blood cell is the only one of these choices that would be considered normal in the immediate postpartum period.

A 2-day-old neonate is receiving phototherapy for jaundice. Which action is essential for the nurse to implement for this client? A. Monitor the temperature carefully B. Instruct the mother to postpone breastfeeding C. Inform provider if the newborn's stool turns bright green D. Avoid covering the newborn's eyes during phototherapy

A. Monitor the temperature carefully The newborn's axillary temperature must be monitored to prevent the newborn from overheating under bright lights and developing hyperthermia. The newborn may also develop dehydration due to hyperthermia. Newborns receiving phototherapy may be removed from under the lights for feeding so they continue to have interaction with their mother. Additionally, early feeding, either formula or breast milk, stimulates bowel peristalsis and helps excrete the excess bilirubin through the feces. The stool of a newborn under phototherapy is often bright green because of the excessive bilirubin being excreted as a result of the therapy. Therefore, this is a normal finding for a newborn in phototherapy and there is no need to inform the provider. This finding must be documented, however. Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the newborn's eyes must always be covered while under bilirubin lights. Commercial phototherapy masks or eye coverings must be used at all times when the newborn is under phototherapy

Which situation would require the administration of Rho(D) immune globulin? A. Mother Rh-negative, baby Rh-positive B. Mother Rh-negative, baby Rh-negative C. Mother Rh-positive, baby Rh-positive D. Mother Rh-positive, baby Rh-negative

A. Mother Rh-negative, baby Rh-positive An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? A. No swelling or edema to the perineal area B. Patient complains that the sitz bath is too cold C. Patient reports she took two sitz baths in 12 hours D. Edges of the perineal laceration are well approximated

A. No swelling or edema to the perineal area Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitates wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma

This reflex starts at 33 weeks gestational age and disappears after 3 months. It occurs with a touch from the corner of the mouth (or upper/lower lip) outward toward the cheek. The response is a head turning toward side of stimulus with mouth opening. What is this reflex? A. Rooting B. Moro C. Galant's response D. Flexor Withdrawal

A. Rooting

The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? A. Rubella vaccine should be given B. A blood transfusion is necessary C. Rh immune globulin is necessary within 72 hours of birth D. A Kleihauer-Betke test should be performed

A. Rubella vaccine should be given A. Correct: This client's rubella titer indicates that she is not immune and that she needs to receive a vaccine B. Incorrect: These data do not indicate that the client needs a blood transfusion C. Incorrect: Rh immune globulin is indicated only if the client has a negative Rh status and the infant has a positive Rh status D. Incorrect: A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test

The nurse wants to assess the crawling reflex in a newborn. How is this reflex assessed?* A. The nurse places the infant in the prone position and applies pressure with the hand to the sole of the foot. In response, the infant should attempt to push against the hand and move the arms and legs in a crawling like motion B. The nurse places the infant in the supine position and applies pressure with the hand to the sole of the foot. In response, the infant should attempt to push against the hand and move the arms and legs in a crawling like motion C. The nurse places the infant in the prone position and applies pressure with the hand to the neck. In response, the infant should attempt to move the arms and legs in a crawling like motion D. The nurse places the infant in the supine position. In response, the infant should attempt to lift the head and move the arms and legs in a crawling like motion

A. The nurse places the infant in the prone position and applies pressure with the hand to the sole of the foot. In response, the infant should attempt to push against the hand and move the arms and legs in a crawling like motion

A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged? A. The woman leaves the infant on her bed while she takes a shower B. The woman continues to hold and cuddle her infant after she has fed her C. The woman reads a magazine while her infant sleeps D. The woman changes her infant's diaper and then shows the nurse the contents of the diaper

A. The woman leaves the infant on her bed while she takes a shower A. Correct: Leaving an infant on a bed unattended is never acceptable for various safety reasons B. Incorrect: This is an appropriate parent-infant interaction C. Incorrect: This is an appropriate maternal action D. Incorrect: This action is appropriate, because the mother is seeking approval from the nurse and notifying the nurse of the infant's elimination patterns

A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? A. Urine output 200 mL for the past 8 hours B. Weight decrease of 2 pounds since delivery C. Drop in hematocrit of 2% since admission D. Pulse rate of 68 beats per minute

A. Urine output 200 mL for the past 8 hours 1. This output is below the accepted minimum for 8 hours 2. This weight decrease following delivery is within normal limits 3. A 2% drop in hematocrit is within normal limits 4. This pulse rate is within normal limits TEST-TAKING TIP: The nurse must divide the amount of urine output by the number of hours. The output in the scenario is equal to 25 mL/hr. This is well below the accepted output of 30 mL/ hr. Plus, because this is a postpartum client, the nurse would expect high urinary outputs. Postpartum clients often have slowed heartbeats

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: A. Vision B. Hearing C. Smell D. Taste

A. Vision The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes

The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary? A. "I may not have a bowel movement until the 2nd postpartum day." B. "If I breastfeed and supplement with formula, I won't need any birth control." C. "I know my normal pattern of bowel elimination won't return until about 8 to 10 days." D. "If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband."

B. "If I breastfeed and supplement with formula, I won't need any birth control." For some women, ovulation resumes as early as 3 weeks postpartum. Therefore contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the patient does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth

The nurse educates expectant parents regarding eye prophylaxis for the newborn. A father asks, "Which infectious diseases could be prevented by this treatment?" Which response by the nurse is best A. "Prophylactic eye treatment for newborns helps prevent syphilis." B. "Sexually transmitted diseases such as gonorrhea can be avoided." C. "Herpes simplex can be prevented with prophylactic eye treatment." D. "Administration of eye antibiotics prevent the vertical spread of trichomonas."

B. "Sexually transmitted diseases such as gonorrhea can be avoided." Most birth settings in the United States and Canada still administer prophylactic eye treatment of erythromycin ointment to help prevent gonorrheal and chlamydia conjunctivitis. Such infections are acquired from the mother as the newborn passes through the birth canal. Syphilis is treated in a pregnant woman with one injection of benzathine penicillin G. The newborn also needs penicillin therapy at birth as well. If a woman contracts herpes simplex virus type 2 during pregnancy, it can be transmitted across the placenta to cause congenital infection in the newborn. To avoid transmission, women with active lesions are usually scheduled for cesarean birth. Additionally, viruses do not respond to antibiotics, as the appropriate pharmacologic agent must be antiviral such as acyclovir or valacyclovir. Oral metronidazole is responsible for eradicating trichomonas infections in pregnant women. Although classified as a Class B pregnancy drug, it may not be prescribed during the first semester of pregnancy to avoid detrimental fetal effects

A mother, G1 P1, who delivered a 2,800 gram baby vaginally 30 minutes earlier, is transferred to the postpartum unit. She pushed for 45 minutes and the placenta was delivered 10 minutes later. She is receiving an intravenous with 20 units oxytocin added. The postpartum nurse questions why the oxytocin was added to the IV bag. Which of the following responses by the transferring nurse is most likely? A. "The medication was added 10 minutes ago to prevent excess bleeding during her transfer." B. "The medication was added immediately after the baby's birth to promote placental delivery." C. "The medication was added after the placenta was delivered because of its rapid separation." D. "The medication was added while she was pushing to speed up the baby's birth."

B. "The medication was added immediately after the baby's birth to promote placental delivery." 1. Patient transfer from labor and delivery to postpartum does not stimulate excess bleeding. It is unlikely that this is the rationale for the medication administration 2. It is likely that the medication was added during the 3rd stage of labor to promote placental delivery 3. Placental delivery usually occurs between 5 minutes and 30 minutes after the birth. This is an unlikely rationale for the medication administration 4. The client's 2nd stage of labor lasted 45 minutes. That is a relatively short period of time for a primipara. As important, 20 units of oxytocin is an unsafe dosage to be administered before the fetus is birthed TEST-TAKING TIP: Postpartum hemorrhage (PPH) is a leading cause of maternal death. One effective means of preventing PPH is active management of the 3 rd stage of labor. In other words, oxytocin is administered after the birth of the baby to promote uterine contraction and placental delivery. The oxytocin is usually added to the client's IV infusion and the infusion is continued until the fl uid is fully absorbed.

The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount? A. Saturated peripad B. 10 to 15 cm (4- to 6-inch) stain on the peripad C. 2.5 to 10 cm (1- to 4-inch) stain on the peripad D. Less than a 1-inch stain on the peripad

B. 10 to 15 cm (4- to 6-inch) stain on the peripad Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: • Scant—less than 2.5 cm (1-inch) stain on the peripad • Light—less than a 10 cm (4 inch) stain • Moderate—less than a 15 cm (6 inch) stain • Heavy—saturated peripad • Excessive—saturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which of the following clients should the nurse assess first? A. A multiparous client at 48 hours postpartum who is being discharged B. A primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate C. A multiparous client at 24 hours postpartum whose infant is in the special care nursery D. A primiparous client at 48 hours after cesarean birth of a term neonate

B. A primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate The primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate should be assessed first because this client is at risk for postpartum hemorrhage. Early postpartum hemorrhage typically occurs during the first 24 hours postpartum. Once the nurse has assessed the client's fundus, lochia, and vital signs, a determination about the stability of the client can be made. After this assessment, the nurse can provide care to the other clients, who are of lesser priority than the newly postpartum primiparous client.

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During your assessment, you notice that both her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: A. Running warm water on her breasts during a shower B. Applying ice to the breasts for comfort C. Expressing small amounts of milk from the breasts to relieve pressure D. Wearing a loose-fitting bra to prevent nipple irritation

B. Applying ice to the breasts for comfort A. Incorrect: This woman is experiencing engorgement, which can be treated by using ice packs (since she is not breastfeeding) and cabbage leaves B. Correct: This intervention is appropriate for treating engorgement in a mother who is bottle feeding C. Incorrect: A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk D. Incorrect: A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation

The nurse is working in the term nursery. Which task should be performed first on a newborn? A. Prepare the circumcision equipment for a two day old newborn B. Assess the five minute APGAR of a newborn C. Perform the gestational age assessment on a 30 minute old newborn D. Obtain a blood sample for metabolic testing on a 24 hour old newborn

B. Assess the five minute APGAR of a newborn B. Correct: The APGAR is done to determine whether a newborn needs help breathing or is having heart trouble. It looks at the newborn's breathing effort, HR, muscle tone, reflexes, and skin color and is the most important initial assessment for a newborn A. Incorrect: This task is not emergent and can be performed later at an appropriate time C. Incorrect: This task is not emergent and can be performed later at anytime during the transition stage of the newborn's nursery care D. Incorrect: This task is not emergent and can be performed at anytime between 24 hours and 7 days old. Typically it is done before the newborn is discharged home

Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client? A. Onset of nausea and vomiting B. Contraction every 90 seconds lasting 70 seconds C. Maternal blood pressure 140/90 D. Early decelerations in the fetal heart rate

B. Contraction every 90 seconds lasting 70 seconds B. Correct: These contractions are too long and too often A. Incorrect: Many laboring clients become nauseated and vomit during labor. Also, common side effects of oxytocin include nausea and vomiting. This would not require the discontinuation of oxytocin C. Incorrect: Maternal hypotension requires discontinuation of oxytocin. This BP is not worrisome D. Incorrect: Early decels are generally not harmful and happen as baby is descending through the birth canal during the later stages of labor. These are not related to the oxytocin infusion

What might a healthcare provider expect to see in a pregnant woman's CBC results at 28 weeks compared to her baseline at 6 weeks? A. Increase in hemoglobin and hematocrit levels. B. Decrease in hemoglobin and hematocrit levels. C. No change in hemoglobin and hematocrit levels. D. Increase in platelet count.

B. Decrease in hemoglobin and hematocrit levels. Due to hemodilutional anemia

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A. Telling the mother not to worry since all breastfed babies have this type of stool B. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements C. Asking the mother what she ate at her last meal D. Suggesting that the mother ask her pediatrician to explain newborn stool patterns to her

B. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements This type of stool is the first stool that all newborns, not just breastfed babies, have. At this early age this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

When the Moro Reflex is stimulated in an infant, the infant will _____________the arms with the palms of the hands turned ___________ and then move the arms ___________ the body.* A. Flex, upward, away from B. Extend, upward, back to C. Flex, downward, back to D. Extend, downward, away from

B. Extend, upward, back to When the Moro Reflex is stimulated in an infant, the infant will EXTEND the arms with the palms of the hand turned UPWARD and then move the arms BACK TO the body

The nurse is assessing a postpartum client who gave birth 10 hours ago. What assessment finding would need further investigation? A. Fundus is at the level of the umbilicus B. Fundus is above the umbilicus and deviated to the right C. Fundus is firm and midline D. Fundus is 2-3 cm below umbilicus

B. Fundus is above the umbilicus and deviated to the right A fundus that is above the umbilicus and deviated to the right is not a normal finding, and may be due to a full bladder. A fundus that is at the level of the umbilicus or 2-3 cm below, firm, and midline is normal.

A nurse is caring for the following four laboring patients. Which clients should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply A. G1 P0000, delivered a fetal demise at 29 weeks' gestation B. G2 P1001, prolonged first stage of labor C. G2 P0010, delivered by cesarean section for failure to progress D. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate E. G4 P3003, with a succenturiate placenta.

B. G2 P1001, prolonged first stage of labor E. G4 P3003, with a succenturiate placenta. 1. Preterm labor clients are not especially at high risk for postpartum hemorrhage 2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH) 3. Cesarean section clients are not especially at high risk for PPH 4. Postdates clients who deliver small babies are not especially at high risk for PPH 5. Clients with a succenturiate placenta are at high risk for PPH TEST-TAKING TIP: The muscles of the uterus of a client who has experienced a prolonged first stage of labor are fatigued. In the postpartum period, therefore, they may fail to contract fully enough to control bleeding at the site of placental separation. A succenturiate placenta is characterized by one primary placenta that is attached via blood vessels to satellite lobe(s). These clients must be monitored carefully for postpartum hemorrhage.

A mother, G6 P6006, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client? A. Seizures B. Hemorrhage C. Infection D. Thrombosis

B. Hemorrhage 1. This client is not especially at high risk for seizures 2. The client should be monitored carefully for signs of postpartum hemorrhage 3. This client is not especially at high risk for infection 4. This client is not especially at high risk for thrombosis TEST-TAKING TIP: An average size baby weighs 2,500 to 4,000 grams. The baby in the scenario is macrosomic. As a result, the mother's uterus has been stretched beyond its expected capacity. In addition, this client is a "grand multipara" or a woman who has delivered 5 or more babies. The client is at high risk for uterine atony, which could result in a postpartum hemorrhage.

The nurse observes that the post-term newborn has meconium-stained amniotic fluid. Which nursing action is essential for this newborn? A. Monitor the newborn's bowel sounds B. Monitor the newborn's respiratory rate C. Monitor the newborn's skin D. Monitor the newborn's intake and output

B. Monitor the newborn's respiratory rate Newborns with meconium-stained amniotic fluid can have difficulty establishing respirations at birth. After the initiation of respirations, the newborn's respiratory rate may remain rapid and coarse bronchial sounds may be heard on auscultation, therefore, monitoring respiratory rate is essential to prevent respiratory distress. The newborn's bowel sounds do not need monitoring, but they must be assessed during the routine physical examination to identify any developing gastrointestinal problems. Meconium is non-irritating and can be washed off the skin. It is not infectious and is in fact, sterile. The passage of meconium indicates that the intestines of the newborn are intact and patent, therefore, it is unnecessary to monitor the intake and output. However, assessing intake and output is still routine during physical assessment.

This reflex begins at about 28 weeks of gestational age and disappears by 5 months. The stimulus is 'dropping' an infant from one hand to the other. The response is abduction with extension followed by adduction with flexion. And lots of crying... A. Rooting B. Moro C. Galant's response D. Flexor Withdrawal

B. Moro

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a: A. Tonic neck reflex B. Moro reflex C. Cremasteric reflex D. Babinski reflex

B. Moro reflex Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. These actions show the Moro reflex. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

After delivery, a newborn is transported to the nursery. The nurse prepares to prevent hypothermia in the newborn. Which action increases radiant heat loss? A. Avoid covering the weighing scale with a blanket or towel B. Move the newborn's incubator closer to the viewing windows C. Decrease the room thermostat to a cooler temperature D. Place the newborn in a room with low humidity

B. Move the newborn's incubator closer to the viewing windows Moving the newborn's incubator closer to the windows causes radiant heat loss. Radiation is the transfer of body heat to a cooler solid object not in contact with the newborn, such as a cold window or air conditioner. Placing the newborn on an uncovered weighing scale is a form of heat loss through conduction. Conduction is the transfer of body heat to a cooler solid object in contact with the newborn. Convection is the flow of heat from the newborn's body surface to the cooler surrounding air. Eliminating drafts and increasing room temperature to an acceptable level for the newborn is an important way to reduce convection heat loss. A room with low humidity promotes evaporative heat loss. Evaporation is the loss of heat through the conversion of a liquid to a vapor

The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? (Select all that apply.) A. Newborn turns head toward stimulus when eliciting rooting reflex B. Newborn's fingers fan out when palmar reflex checked C. Newborn forces tongue outward when tongue touched D. Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited E. Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect

B. Newborn's fingers fan out when palmar reflex checked The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex. When eliciting rooting reflex, the characteristic response is for the baby to turn head toward stimulus and open mouth. Extrusion is elicited by touching tongue, and newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers form a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe.

You note that when a finger is placed under the toes of a newborn, the toes will curl downward. This is known as the __________?* A. Babinski reflex B. Plantar grasp reflex C. Tonic Neck reflex D. Step reflex

B. Plantar grasp reflex

A primagravida asks the nurse about the purpose of the RhoGam injection. What would be the best explanation by the nurse? A. RhoGam changes the Rh positive fetus to Rh negative B. RhoGam prevents the mother from forming Rh antibodies C. RhoGam inhibits Rh antibodies in the newborn infant D. RhoGam destroys antibodies in the RH positive mother

B. RhoGam prevents the mother from forming Rh antibodies B. Correct: RhoGam is an immunoglobulin given via injection to an Rh negative mother following the birth of an Rh positive infant. The mixing of mother and fetal blood during birth causes the mother to develop antibodies which can be fatal to the next fetus. RhoGam prevents the formation of these antibodies in the mother A. Incorrect: RhoGam has no effect on the Rh factor in the fetus. RhoGam is administered to the mother and does not alter the Rh factor at all. RhoGam works to prevent antibody formation in the mother C. Incorrect: RhoGam is never given to an infant because the fetus does not form RH antibodies. Only the mother will form antibodies D. Incorrect: RhoGam does not "destroy" antibodies; rather, it prevents the actual formation of antibodies in the mother. Also, RhoGam is only given to Rh negative mothers

A pregnant woman comes into the clinic at 28 weeks gestation. The provider orders a CBC, and you notice her Hgb level is at 11 g/dL, as compared to her Hgb level of 14 g/dL from her first prenatal visit at 6 weeks gestation. How might you go about discussing this finding with the patient? A. Tell the patient she is not eating enough iron-rich foods, like broccoli and beef B. Tell the patient this is an expected finding due to the increased plasma volume from pregnancy C. Explain to the patient she may need a blood transfusion D. Accuse the patient of not taking Folic acid daily, like she was recommended

B. Tell the patient this is an expected finding due to the increased plasma volume from pregnancy

Which fundal assessment finding at 12 hours after birth requires further assessment? A. The fundus is palpable at the level of the umbilicus. B. The fundus is palpable two fingerbreadths above the umbilicus C. The fundus is palpable one fingerbreadth below the umbilicus. D. The fundus is palpable two fingerbreadths below the umbilicus

B. The fundus is palpable two fingerbreadths above the umbilicus. The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation? A. Her bleeding needs to be reported to the physician immediately B. The increased lochia occurs from lochia pooling in the vaginal vault C. The increase in lochia may be an early sign of postpartum hemorrhage D. This increase in lochia usually indicates retained placental fragments

B. The increased lochia occurs from lochia pooling in the vaginal vault Lochia can be expected to increase when the client first ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and flows out when the client arises. If the client had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed and the physician would be notified. Early postpartum hemorrhage occurs during the first 24 hours, but typically the fundus is soft or "boggy." The client's fundus here is firm and midline. Late postpartal hemorrhage, occurring after the first 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site.

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? A. Deep tendon reflexes of plus three B. Urine output of 80 mL over four hours C. Respiratory rate of 24 breaths/minute D. Severe headache with blurred vision

B. Urine output of 80 mL over four hours B. Correct: Preeclampsia is a condition in which the client's blood pressure is consistently elevated, with a systolic greater than 140 mm Hg and a diastolic above 90 mm Hg. The greatest main concern is decreased perfusion to the placenta, endangering mother and fetus, potentially accompanied by seizures, kidney or liver failure. This client has had only 80 mL of urine in four hours, indicating an output less than the minimum required of 30 mL per hour. This indication of possible kidney failure should be reported to the primary healthcare provider immediately A. Incorrect: Deep tendon reflexes (DTR'S) range from 0 to +5 and are used to assess the neurologic integrity of the body. Normal reflexes for the body range around +2 but become elevated in preeclampsia. The possibility of seizures increases as DTR's increase over the normal range. This symptom is serious but expected in a client with preeclampsia. The nurse should continue monitoring this C.Incorrect: As blood pressure increases in the preeclampsic client, both respirations and heart rate would also begin to elevate. The client may display excessive swelling of hands and feet, occasionally accompanied by facial swelling. Although a respiratory rate of 24 is a bit elevated, it is nothing the nurse needs to report immediately D. Incorrect: The combination of increased blood pressure and swelling in preeclampsia frequently results in severe headaches and blurred vision. If the blood pressure reaches life-threatening levels, clients have been known to develop blindness because of retinal response to the decreased body perfusion. Although headache and blurred vision are serious symptoms, this is not completely unexpected and therefore does not need to be reported to the primary healthcare provider immediately

What is NOT a postpartum practice for preventing infections? A. Not letting the mother walk barefoot at the hospital B. Using sitz baths and heat lamps more frequently to kill germs C. Having staff members with conditions such as strep throat, conjunctivitis, and diarrhea stay home D. Instructing the mother to change her perineal pad from front to back each time she voids or defecates

B. Using sitz baths and heat lamps more frequently to kill germs A. Incorrect: Walking barefoot and getting back into bed can contaminate the linens B. Correct: Heat lamps and sitz baths are now used less frequently because they are hard to keep sterile C. Incorrect: Staff members with infections need to stay home until they are no longer contagious D. Incorrect: She should also wash her hands before and after these functions

With regard to rubella and Rh issues, nurses should be aware that: A. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus B. Women should be warned that the rubella vaccination is teratogenic and they must avoid pregnancy for 2 to 3 months after vaccination C. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant D. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations

B. Women should be warned that the rubella vaccination is teratogenic and they must avoid pregnancy for 2 to 3 months after vaccination A. Incorrect: Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated B. Correct: Women should understand they must practice contraception for 2 to 3 months after being vaccinated C. Incorrect: Rh immune globulin is administered intramuscularly (IM); it should never be given to an infant D. Incorrect: Rh immune globulin suppresses the immune system and therefore might thwart the rubella vaccination

A postpartum patient asks, "Will these stretch marks ever go away?" Which is the nurse's best response? A. "No, never." B. "Yes, eventually." C. "They will fade to silvery lines but won't disappear completely." D. "They will continue to fade and should be gone by your 6-week checkup."

C. "They will fade to silvery lines but won't disappear completely." Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear

The nurse provides discharge instructions to a mother about umbilical cord care. Which statement by the mother indicates effective health teaching? A. "My child can have a tub bath every day." B. "I will clean the stump with antiseptics daily." C. "Water and soap can be used if the stump is dirty." D. "I need to apply an antibiotic ointment every day."

C. "Water and soap can be used if the stump is dirty." The dry care method using only soap and water for umbilical cord care has been recommended by the WHO as it is effective and more practical than using antiseptics. Additionally, dry care is less expensive for healthy newborns in hospital settings in high-income countries. Daily bathing of the newborn results in longer cord separation times, increasing the risk of infection. Cleaning the stump daily with antiseptics is only applicable if the newborn is at a high risk of developing an infection, such as newborns who were born at home. Furthermore, the application of antiseptic solutions can delay the separation of the umbilical cord and does not provide any benefit. The use of antibiotic ointments is only indicated when an infection is present and is not a part of the routine cord care of a newborn

Which woman is most at risk for bladder distention after a normal vaginal delivery? A. A woman who had IV fluids running during labor B. A woman who had a midline episiotomy C. A woman who had epidural anesthesia D. A woman who had an active labor lasting 12 hours

C. A woman who had epidural anesthesia Every woman is at risk following delivery, and the nurse must assess voiding patterns after delivery. However, the biggest risk factor is anesthesia, which affects the sensory nerves, because the woman is unaware of the need to empty her bladder. Nerve blocks also may affect motor nerves, making micturition difficult. IV fluids may cause more urine to be produced, but should not promote retention of urine. A midline episiotomy will not promote urinary retention, and a 12-hour labor is not abnormal.

A 24-year-old primipara is rooming in with her new infant. Which behavior indicates a need for further assessment? A. Verbalizing concerns over the shape of the baby's head B. Reluctance to hand the baby to staff for assessment C. Allowing the baby to cry in the bassinette and learn self-soothing D. Keeping the baby constantly on her chest

C. Allowing the baby to cry in the bassinette and learn self-soothing The mother should be responsive to the newborn at this time. Failure of the mother to respond to the infant's needs may indicate disordered bonding or the need for further teaching on normal newborn behavior. Being reluctant to give the baby to staff for assessments, verbalizing concern about possible injury to the baby, and holding it for long periods are signs of appropriate bonding.

The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding? A. Weigh the peripad B. Replace the peripad C. Contact the health care provider D. Document the finding in the patient's chart

C. Contact the health care provider. The lochia of the cesarean birth mother will go through the same phases as that of the woman who had a vaginal birth; however, the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and an indication of hemorrhage. The health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss; but, this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits

Which measure is optimal in order to prevent abdominal distention following a cesarean birth? A. Rectal suppositories B. Carbonated beverages C. Early and frequent ambulation D. Tightening and relaxing abdominal muscles

C. Early and frequent ambulation Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention. Abdominal strengthening will not prevent distention

When assessing the A of the acronym REEDA, the nurse should evaluate the: A. Skin color B. Degree of edema C. Edges of the episiotomy D. Episiotomy for discharge

C. Edges of the episiotomy In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage

Vitamin K is given to the newborn to: A. Reduce bilirubin levels B. Increase the production of red blood cells C. Enhance ability of blood to clot D. Stimulate the formation of surfactant

C. Enhance ability of blood to clot Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K is required for the production of certain clotting factors. Vitamin K does not stimulate the formation of surfactant

A client's membranes spontaneously rupture at 10 cm dilation and +2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action? A. Emergency cesarean delivery B. Immediate high forceps delivery C. Equipment for immediate suctioning of the newborn D. Administration of IV oxytocin

C. Equipment for immediate suctioning of the newborn C. Correct: Green stained fluid indicates fetal passage of meconium. The fetus must be suctioned by the healthcare provider when the head is still on the perineum and before the baby takes its first breath. This will remove any particulate matter from the meconium that may cause aspiration A. Incorrect: Delivery will probably occur soon and vaginal delivery is preferable to cesarean. This is an unrealistic and inappropriate action for this client B. Incorrect: High forceps are never indicated and would not provide safe delivery for the baby. The concern is the meconium stained fluid and potential aspiration for the baby D. Incorrect: The meconium passage is an indicator of fetal stress, and increased uterine contractions may stress the fetus further. This would not be safe for the baby or the mother at this stage of labor

Excessive blood loss after childbirth can have several causes; the most common is: A. Vaginal or vulvar hematomas B. Unrepaired lacerations of the vagina or cervix C. Failure of the uterine muscle to contract firmly D. Retained placental fragments

C. Failure of the uterine muscle to contract firmly A. Incorrect: Although these are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause B. Incorrect: Although this is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause C. Correct: Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distension D. Incorrect: Although this is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? A. Pulse rate of 50 B. Temperature of 38ºC (100.4ºF) C. Firm fundus, but excessive lochia D. Lightheaded when moving from a lying to standing positio

C. Firm fundus, but excessive lochia Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38ºC (100.4ºF) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand

This reflex begins at 32 weeks and disappears by 2 months. The stimulus is tactile stimulation along spine. The response is ipsilateral trunk flexion (concave on stimulated side) and head turns toward stimulated side. If retained, this reflex can cause tightness on convex side and be a factor in spinal asymmetry and scoliosis A. Rooting B. Moro C. Galant's response D. Flexor Withdrawal

C. Galant's response

If a woman is at risk for thrombus and is not ready to ambulate, nurses might intervene by doing all of these interventions except: A. Putting her in TED hose and/or SCD boots B. Having her flex, extend, and rotate her feet, ankles, and legs C. Having her sit in a chair D. Notifying the physician immediately if a positive Homans' sign occurs

C. Having her sit in a chair A. Incorrect: Antiembolic stockings (TED hose) and sequential compression devices (SCD boots) are recommended. Just sitting in a chair will not help B. Incorrect: Bed exercises such as these are useful. Just sitting in a chair will not help C. Correct: Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear might D. Incorrect: A positive Homans' sign (calf muscle pain or warmth, redness, or tenderness) requires the physician's immediate attention.

After a vaginal delivery, the nurse assesses a large-for-gestational-age (LGA) newborn and finds that the axillary temperature is 96℉ (35.6℃) and the newborn's lips and hands are trembling. Which action by the nurse is next? A. Wrap the newborn in warm blankets B. Feed the newborn with formula C. Obtain serum glucose level D. Stimulate the newborn to cry

C. Obtain serum glucose level The newborn is exhibiting signs of hypoglycemia, therefore, the nurse must first determine the newborn's glucose level. Large-for-gestational age (LGA) newborns require large amounts of nutritional stores to sustain their weight. If the mother had poorly controlled diabetes, the newborn would have had an increased blood glucose level in utero to match the mother's glucose level, causing the newborn to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, causing rebound hypoglycemia. Before any intervention is initiated, the nurse must initially check the blood glucose level to determine the appropriate intervention to implement

The nurse is caring for a newborn immediately after delivery. Which action by the nurse shows an understanding of the newborn's thermoregulatory ability? A. Suctions the newborn's nostrils with a bulb syringe B. Inspects the condition of the newborn's umbilical cord C. Places the newborn under a radiant warmer D. Obtains an Apgar score during the first one and five minutes

C. Places the newborn under a radiant warmer

A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider about: A. Bleeding that becomes lighter each day B. Clots the size of golf balls C. Saturating a pad in an hour D. Lochia that lasts longer than 1 week

C. Saturating a pad in an hour A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum

The nurse suddenly bumps the bassinet of a newborn, eliciting the startle reflex. Which actions by the newborn show this reflex? A. The big toe dorsiflexes, followed by fanning of the other toes B. The fingers flex to enclose the nurse's fingers and cling C. The arms, legs, and neck extend then brings the arms together D. The head turns to one side, the aligned arm straightens, the opposite arm bends

C. The arms, legs, and neck extend then brings the arms together The startle, or Moro, reflex, occurs when the newborn is startled by something loud or abrupt. The newborn extends his arms, legs, and neck, and then rapidly brings both arms together. This reflex disappears after two months. The Babinski reflex is elicited when the sole of the foot is stroked, then the big toe bends backward (dorsiflexion) toward the top of the foot and the other toes fan out. This is a normal reflex up to about two years of age. The palmar grasp reflex occurs when the palm of a newborn is stroked, then the newborn closes their fingers in a grasp. The tonic neck reflex is elicited when the newborn's head is turned to one side and the arm on that side stretches out, while the opposite arm bends at the elbow. This is often called the "fencing" position

The nurse assesses the mother of a newborn who is breastfeeding. Which assessment finding indicates ineffective breastfeeding of the newborn? A. The newborn's mouth grasps the mother's nipple with the tongue down B. The newborn swallows audibly, spontaneously, and frequently C. The newborn smacks their lips loudly during breastfeeding D. The newborn turns to the breast when its cheek is stroked with a nipple

C. The newborn smacks their lips loudly during breastfeeding The newborn who smacks its lips when breastfeeding shows the poor attachment and may cause injury to the mother's nipples. If the newborn is well-attached at the breast, then the newborn can suck effectively. The newborn shows a good latch when their mouth grasps the nipple with the tongue reaching well underneath the breast tissue. The newborn is able to suck effectively when they take slow, deep suckles followed by a visible or audible swallow about once per second. Sometimes the newborn may pause for a few seconds, allowing the ducts to sill up with milk again. To stimulate the newborn's rooting reflex before breastfeeding, the mother may brush the newborn's cheek with a breast nipple. The newborn will then turn toward the breast

The nurse educates a mother regarding the limitations of breastfeeding her newborn. Which statement by the mother indicates an understanding of the teaching? A. "I may drink alcohol a few hours before breastfeeding my baby." B. "My breast milk won't be affected by cigarette smoking." C. "I need to stop breastfeeding if my nipples become sore." D. "Consistent breastfeeding stops ovulation and my period."

D. "Consistent breastfeeding stops ovulation and my period."

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman: A. "Didn't you like your lunch?" B. "Does your doctor know that you are planning to eat that?" C. "What is that anyway?" D. "I'll warm the soup in the microwave for you."

D. "I'll warm the soup in the microwave for you." A. Incorrect: Cultural dietary preferences must be respected B. Incorrect: Women may request that family members bring favorite or culturally appropriated foods to the hospital C. Incorrect: Cultural dietary preferences must be respected. A statement such as this does not show cultural sensitivity D. Correct: This statement shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response

A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will fade after birth due to A. Increased estrogen B. Increased progesterone C. Decreased human placental lactogen D. Decreased melanocyte-stimulating hormone

D. Decreased melanocyte-stimulating hormone Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth. Progesterone levels decrease after birth. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation

The nurse assesses an 8-hour-postpartum client. Findings include lochia rubra, with a firm fundus at the level of the umbilicus. What nursing action is indicated? A. Massage the fundus to prevent early postpartum hemorrhage B. Administer Methergine to stop the bleeding C. Call the primary healthcare provider/CNM and prepare for a pelvic exam D. Document findings and continue to monitor

D. Document findings and continue to monitor The client's findings are within normal limits. Document findings and continue to monitor. Early postpartum hemorrhage presents with a boggy, nonfirm fundus. Massage is used to encourage the fundus to contract, and therefore is not indicated with this client's findings. Administering Methergine to control excessive bleeding is not necessary in this situation.

If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided? A. No specific instructions B. Drinking plenty of fluids to prevent fever C. Recommendation to stop breastfeeding for 24 hours after the injection D. Explanation of the risks of becoming pregnant within 28 days following injection

D. Explanation of the risks of becoming pregnant within 28 days following injection Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding

To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize? A. Assess lochial flow rather than palpating the fundus. B. Palpate forcefully through the abdominal dressing. C. Place hands on both sides of the abdomen and press downward. D. Gently palpate, applying the same technique used for vaginal deliveries

D. Gently palpate, applying the same technique used for vaginal deliveries Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked

Which finding could prevent early discharge of a newborn who is now 12 hours old? A. Birth weight of 3000 g B. One meconium stool since birth C. Voided, clear, pale urine three times since birth D. Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast

D. Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast A. Incorrect: This is a normal infant finding and would not prevent early discharge B. Incorrect: This is a normal infant finding and would not prevent early discharge C. Incorrect: This is a normal infant finding and would not prevent early discharge D. Correct: This finding indicates that the infant is having some difficulty with breastfeeding. The infant needs to complete at least two successful feedings (normal sucking and swallowing) before an early discharge

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse might try is: A. Pouring water from a squeeze bottle over the woman's perineum B. Placing oil of peppermint in a bedpan under the woman C. Asking the physician to prescribe analgesics D. Inserting a sterile catheter

D. Inserting a sterile catheter A. Incorrect: Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early on B. Incorrect: The oil of peppermint releases vapors that may relax the necessary muscles. It is easy, noninvasive, and should be tried early on C. Incorrect: If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means could be tried first, but medications still come before insertion of a catheter D. Correct: Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain pills).

Which maternal event is abnormal in the early postpartal period? A. Diuresis and diaphoresis B. Flatulence and constipation C. Extreme hunger and thirst D. Lochial color changes from rubra to alba

D. Lochial color changes from rubra to alba For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor

A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? A. Engorgement B. Mastitis C. Blocked milk duct D. Low milk supply

D. Low milk supply 1. The nurse would not expect to see engorgement 2. The nurse would not expect to see mastitis 3. The nurse would not expect to see a blocked milk duct 4. The nurse would expect that the woman would have a low milk supply TEST-TAKING TIP: The placenta produces the hormones of pregnancy, including estrogen and progesterone. When placental fragments are retained, those hormones are still being produced. Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. Women who have retained placental fragments, therefore, often complain of an insufficient milk supply for their babies. Women with retained placental fragments are also at high risk for postpartum hemorrhage and intrauterine infection.

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. The nurse's first action is to: A. Begin an intravenous (IV) infusion of Ringer's lactate solution B. Assess the woman's vital signs C. Call the woman's primary health care provider D. Massage the woman's fundus

D. Massage the woman's fundus A. Incorrect: The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action B. Incorrect: Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse's first action C. Incorrect: The physician would be notified after the nurse completes the assessment of the woman D. Correct: The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.

The nurse is reviewing laboratory values and flowsheet data for her client on postpartum day 1. Which of the following would the nurse point out to the nurse-midwife or primary healthcare provider? A. WBC count of 25,000/mm3 B. Urine output of 3000 ml in 24 hours C. Decrease in hematocrit from 32% to 31% D. Maternal heart rate of 120 bpm

D. Maternal heart rate of 120 bpm 120 bpm is tachycardia, which may indicate hypovolemia. Mild physiologic bradycardia is expected in the postpartum period. WBC counts of 25,000-30,000/cubic mm, increased urine output, and mild anemia with a slight decrease in hematocrit are expected findings.

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following? A. Trauma during labor and birth B. Moderate fundal massage after birth C. Lengthy and prolonged second stage of labor D. Overdistention of the uterus from hydramnios

D. Overdistention of the uterus from hydramnios The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and birth can also contribute to uterine atony during the postpartum period. Trauma during labor and birth is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean birth for breech presentation. Therefore, it is unlikely that she had a long labor.

Postpartal overdistention of the bladder and urinary retention can lead to which complication? A. Fever and increased blood pressure B. Postpartum hemorrhage and eclampsia C. Urinary tract infection and uterine rupture D. Postpartum hemorrhage and urinary tract infection

D. Postpartum hemorrhage and urinary tract infection Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth

The nurse is at the bedside during the recovery period immediately after a vaginal birth at term. The pregnancy, labor, and birth were uncomplicated. The mother experiences a visible, full body tremor, and states, "Oh no! I can't stop shaking! What's wrong with me?" What are the most appropriate nursing actions? A. Overhead page the nurse-midwife or primary healthcare provider and notify the charge nurse B. Increase the rate of IV fluid and postpartum Pitocin C. Recline the head of the bed and elevate the foot D. Reassure the client and cover her with warm blankets.

D. Reassure the client and cover her with warm blankets Significant tremors are common immediately postpartum and are thought to be caused by fluid shifts, biochemical changes, and entry of fetal cells into the mother's circulation during birth. No interventions are needed beyond reassuring the mother that this is common and helping her stay warm

A multiparous client visits the urgent care center 5 days after a vaginal birth, experiencing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, "Why am I continuing to bleed like this?" The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following? A. Uterine atony B. Cervical lacerations C. Vaginal lacerations D. Retained placental fragments

D. Retained placental fragments The most likely cause of delayed postpartum hemorrhage is retained placental fragments. The client may be scheduled for a dilatation and curettage to remove remaining placental fragments. Uterine atony, cervical lacerations, and vaginal lacerations are commonly associated with early, not late, postpartum hemorrhage

You note when a 2-month-old is held upright with the legs and feet touching the surface, the infant will appear to be walking on the surface. This reflex is called the?* A. Bauer Crawling Reflex B. Push-to-Walk Reflex C. Babinski Reflex D. Step Reflex

D. Step Reflex

Select the option below that best describes how to assess the palmar grasp reflex:* A. Stroke the cheek of the infant and assess if the head turns toward the stimuli. B. Stroke the sole of the foot starting at the heel to the outward part of the foot and assess if the big toe bends back and the other toes spread out. C. Hold the infant upright with the legs and feet touching a surface and assess if the infant will move the legs in a stepping motion. D. Stroke the inside of the infant's hand with an object and assess if the hand closes around the object.

D. Stroke the inside of the infant's hand with an object and assess if the hand closes around the object. Stroking the inside of the infant's hand with an object and assessing if the hand closes around the object helps assess the palmar grasp reflex.

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care? A. Have the patient drink carbonated beverages to promote urinary excretion. B. Tell the patient that because of postpartum diuresis there is less risk to develop dehydration. C. Limit fluid intake to prevent polyuria. D. Teach the patient to perform pelvic floor exercises to combat potential stress incontinence

D. Teach the patient to perform pelvic floor exercises to combat potential stress incontinence Educating the patient to use pelvic floor exercises (Kegel exercises) will help strengthen pelvic floor muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the patient is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? A. The woman is a gravida 2, para 2 B. The woman had a vacuum-assisted birth C. The woman received epidural anesthesia D. The woman has an episiotomy

D. The woman has an episiotomy A. Incorrect: A multiparous classification is not an indication for these orders B. Incorrect: A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions C. Incorrect: Use of epidural anesthesia has no correlation with these orders D. Correct: These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids.

During an assessment of an infant, you note that when the infant's head is turned to the right side, the leg and arm on the right side will extend, while the leg and arm on the left side will flex. You document this as what type of reflex?* A. Rooting Reflex B. Sucking Reflex C. Moro Reflex D. Tonic Neck Reflex

D. Tonic Neck Reflex When the infant's head is turned to a particular side, the leg and arm on that side will extend, while the leg and arm on the opposite side will flex

The period encompassing the first 1 to 2 hours after birth often is referred to as the ____________________ stage of labor.

Fourth

You assess that fundus is firm, bladder is empty, and lochia is bright red flowing briskly from the vagina. What do you think is happening?

Fundus is firm→the uterus has to contract down (called involution), it's not empty, the muscle contraction of the uterus (feels like menstrual cramps for most women) & it has to contract down to make sure the BVs are cut off. So firm is the word we use to describe the uterus after childbirth & cantaloupe is the analogy→so around the time of birth we usually feel the fundus (top of uterus) at around the umbilicus & it feels like a cantaloupe. If it's NOT firm, we refer to it as boggy (soft, indentible). We want it firm so the uterus is contracting, so it's shutting off those BVs so the Mom doesn't bleed to death This pt is firm, her bladder is empty, & the lochia is bright red flowing briskly from the vagina. What are we describing here? Her uterus being firm is good/normal & her bladder being empty is also good BUT briskly is not an okay word & flowing is also not an okay word here. So, she's hemorrhaging from somewhere Our 1st priority assessment is the fundus & in this situation it's firm, thankfully. But if it wasn't firm, we'd massage the fundus as the 1st nursing intervention if we have an unfirm or an atonic or a boggy uterus/fundus. If she calls us & says "I feel like I'm gushing" then the 1st thing we do when we run into the room is feel the fundus & if it's not hard like a cantaloupe, we're going to massage it. You WILL/CAN feel it firming up. When it's firm, you stop massaging it b/c it could affect the muscle fibers & cause the uterus to go back to being boggy. So the answer is always massaging the fundus if it's boggy or if she's bleeding. BUT in this scenario, the fundus is firm so there are some other things that can cause it