Maternity

Acrocyanosis is normal and occurs intermittently in a newborn True or False?

True Rationale: Acrocyanosis occurs in the newborn in response to exposure to cold.

Hypercapnia, hypoxia, and _______ resulting from normal labor become the stimuli for initiating respirations in the newborn.

Acidosis

The most common cranial nerve trauma involves the facial nerve True or False?

True Rationale: The most common cranial nerve trauma is facial nerve palsy. It may be attributed to pressure from forceps use or from in utero positioning.

The _______ fontanel is triangular.

posterior

If required immediately after birth, a newborn's mouth is suctioned first, then the nose. True or False?

True Rationale: Debris is suctioned first from the back of the mouth to avoid aspiration into the lungs when the nose is suctioned

A postpartum client who is bottle feeding her newborn asks "When should by period return?" Which response by the nurse would be most appropriate? A. "It difficult to say, but it will probably return in about 2-3 weeks." B. "It varies, but you can estimate it returning in about 7-9 weeks." C. "You won't have to worry about it returning for at least 3 months." D. "You don't have to worry about that now. It'll be quite awhile."

B. "It varies, but you can estimate it returning ina bout 7-9 weeks". Rationale: For non-lactating woman, menstruation resumes 7-9 weeks after giving birth, with the first cycle being anovulatory. For lactating woman, menses can return anytime from 2-18 months after birth

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? A. 1000ml B. 500ml C. 750ml D. 250ml

A. 1000ml Rationale: Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? A. magnesium sulfate B. betamethasone C. nifedipine D. indomethacin

A. magnesium sulfate Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. It is not a tocolytic agent.

The nurse is preparing to administer an intramuscular injection of vitamin K to a newborn. The nurse will ensure the amount per injection is within which range? A. no more than 0.25 mg B. 0.5 to 1.0 mg C. 1.25 to 1.75 mg D. 2.0 to 2.5 mg

B. 0.5 to 1.0 mg Rationale: The efficacy of vitamin K in preventing early vitamin K deficiency bleeding is firmly established and has been the standard of care since the American Academy of Pediatrics (AAP) recommended it in the early 1960s. The AAP (2019) recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg.

The ______ reflex is also called the embrace reflex.

Moro

Respiratory distress syndrome occurs in premature infants due to a lack of surfactant in the lungs. True or False?

True Rationale: In the premature infant, lung immaturity and inadequate surfactant production lead to the development of respiratory distress syndrome.

A newborn with transient tachypnea typically requires mechanical ventilation True or False?

False Rationale: Transient tachypnea of the newborn resolves within 72 hours of age and does not require mechanical ventilation. Oxygen may be supplemented via nasal cannula or oxygen hood.

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team? A. Sudden shortness of breath B. Bradycardia C. Unrelieved pain D.Bradypnea

A. Sudden shortness of breath Rationale: Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. It must be reported to the care team so proper interventions may be taken. Other symptoms can include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, DIC, and pulmonary edema.

A comprehensive assessment of the newborn should occur immediately after birth. True or False?

False Rationale: Immediately after birth a rapid assessment is performed to determine the newborn's stability. After the newborn has successfully completed transition, the comprehensive assessment will be performed.

The nurse is teaching a prenatal class on potential problems during pregnancy to a group of expectant parents. The risk factors for placental abruption (abruptio placentae) are discussed. Which comment validates accurate learning by the parents? A. "Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain." B. "Since I am over 30, I run a much higher risk of developing this problem." C. "If I develop this complication, I will have bright red vaginal bleeding," D. "I need a cesarean section if I develop this problem."

A. "Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain." Rationale: Placental abruption (abruptio placentae) occurs when there is a spontaneous separation of the placenta from the uterine wall. It can occur anywhere on the placenta and will cause painful, dark red vaginal bleeding. If the abruption is small, the ob/gyn will try to deliver the fetus vaginally. But if severe bleeding occurs or there is fetal distress, a cesarean birth will be performed. Women older than 35 are also at higher risk for developing placental abruption.

A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear within which time frame after birth? A. 3 months B. 4 months C. 5 months D. 2 months

A. 3 Months Rationale: Postpartum psychosis generally surfaces within 3 months of giving birth.

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe? A. Administer oxytocin diluted as a "piggyback" infusion. B. Administer oxytocin in a 20 cc bolus of saline. C. Administer oxytocin diluted in the main intravenous fluid. D. Administer oxytocin in two divided intramuscular sites.

A. Administer oxytocin diluted as a "piggyback" infusion. Rationale: Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

The nurse recognizes that documenting accurate blood pressures is vital in the diagnosing of preeclampsia, severe preeclampsia and eclampsia. The nurse suspects preeclampsia based on which finding? A. BP of 140/90 mm Hg last week and at current visit after 20 weeks' gestation B. BP of 120/90 mm Hg on three occasions after 20 weeks' gestation C. BP of 130/90 mm Hg on three occasions 3 hours apart D. BP of 160/110 mm Hg on two occasions after 28 weeks' gestation

A. BP of 140/90 mm Hg last week and at current visit after 20 weeks' gestation Rational: Gestational hypertension is diagnosed when systolic blood pressure is over 140 mm Hg and/or diastolic pressure is over 90 mm Hg on at least two occasions at least 4 to 6 hours apart after the 20th week of gestation in women known to be normotensive prior to this time and prior to pregnancy. Severe preeclampsia (i.e., preeclampsia with severe features) may develop suddenly or within days and bring with it high blood pressure of more than 160/110 mm Hg, cerebral and visual symptoms, and pulmonary edema.

A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? A. Look for late decelerations on monitor, which is associated with fetal anoxia. B. Monitor fetal blood pressure for signs of shock (low BP, high FHR) C. Monitor fetal movements to ensure they are neurologically intact. D. Monitor heart rate for tachycardia.

A. Look for late decelerations on monitor, which is associated with fetal anoxia. Rationale: A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the FHR is not showing late deceleration.

After birth, the nurse assess the baby's umbilical cord. What is the expected appearance of the umbilical cord? A. Pale yellow in appearance, with 2 arteries and 1 vein B. Greenish-yellow in appearance, with 2 arteries and 1 vein C. Pale yellow in appearance, with 1 artery and 2 veins D. Greenish-yellow in appearance, with 1 artery and 2 veins

A. Pale yellow in appearance, with 2 arteries and 1 vein Rationale: The umbilical cord contains 2 arteries and 1 vein surrounded by Wharton's jelly. The appearance of the cord at birth is plump and pale yellow in color. If the cord has a greenish color, it is a sign of meconium having been present in the amniotic fluid surrounding the infant prior to birth.

The nurse assesses the baby's head. What does the nurse expect to find when palpating the anterior fontanel? A. Soft, flat, and diamond shaped B. Firm, raised, and diamond shaped C. Soft, flat, and triangle shaped D. Firm, raised, and triangle shaped

A. Soft, flat, and diamond shaped Rationale: The anterior fontanel is diamond shaped. The expected finding if flat and soft. If the fontanel is firm or raised, it is a sign of increased intracranial pressure. The posterior fontanel is triangle shaped

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? A. Symptoms include fever, chills, malaise, and localized breast tenderness. B. The most common pathogen is group A streptococcus (GAS). C. A breast abscess is a common complication of mastitis. D. Mastitis usually develops in both breasts of a breastfeeding client.

A. Symptoms include fever, chills, malaise, and localized breast tenderness. Rationale: Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging? A. Use McRoberts maneuver. B. Attempt to push in one of the fetus's shoulders. C. Use Zavanelli maneuver. D. Apply pressure to the fundus.

A. Use McRoberts maneuver. Rationale: McRoberts maneuver intervention is used with a large baby who may have shoulder dystocia and requires assistance. The legs are sharply flexed by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is outside the scope of practice for the LPN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

The nurse notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation (dilatation). Assessment reveals a prolapsed umbilical cord. Which action should the nurse prioritize? A. Use fingers to press upward on the presenting part. B. Place client in a knee-chest position. C. Prep for immediate cesarean delivery. D. Turn client to her left side.

A. Use fingers to press upward on the presenting part. Rationale: If the woman presents with a visible prolapse of the cord, quickly place her in bed and gently palpate the cord for pulsations to verify fetal viability. Then use fingers to press upward on the presenting part. Continue to hold the presenting part of the cord until delivery of the infant. If you discover the condition and are unable to call for help, place the client in knee-chest position, call for help, and then continue to intervene as previously described. Keeping the pressure of the fetus off the cord improves fetal circulation. Replacing the cord could knot it; allowing it to dry would constrict cord blood vessels. Turning the woman to the left side is not the intervention of choice. Another nurse will be helping prepare this client for immediate cesarean delivery.

The nurse manager is reviewing all the L & D clients on the unit in order to prepare assignments for the nursing staff. For which clients would augmentation of labor with oxytocin be contraindicated, or used cautiously? Select all that apply. A. a 30-year-old multipara woman who has experienced premature rupture of membranes 5 days ago but is just now reporting it to the health care provider B. a 27-year-old primipara in active labor for the past 4 hours C. a 44-year-old primipara diagnosed with gestational diabetes in active labor for the past 6 hours D. a 33-year-old female who is 32 weeks' gestation in labor with twins E. an 18-year-old primipara client who is experiencing acute pain and refusing an epidural catheter

A. a 30-year-old multipara woman who has experienced premature rupture of membranes 5 days ago but is just now reporting it to the health care provider C. a 44-year-old primipara diagnosed with gestational diabetes in active labor for the past 6 hours D. a 33-year-old female who is 32 weeks' gestation in labor with twins Rationale: Augmentation or initiation of labor carries risks; it must be used cautiously in women with multiple gestation, polyhydramnios, grand parity, or those who are older than age 40. Prolonged rupture of the membranes might make induction necessary before the usual 39 weeks' gestation period. Four hours of active labor is a normal occurrence. An 18-year-old woman in labor experiencing acute pain is also a normal occurrence.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes the client's history of asthma. Which medication if prescribed would the nurse question? A. carboprost B. methylergonovine C. oxytocin D. dinoprostone

A. carboprost Rationale: Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, and methylergonovine should not be given to a woman who is hypertensive. Dinoprostone and methylergonovine can be used in pregnant clients with asthma, although should be used cautiously. Dinoprostone may cause hypotension, nausea/vomiting, diarrhea and temperature elevation.

A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect? A. ensures passage of all the products of conception B. suppresses the immune response to prevent isoimmunization C. alleviates strong uterine cramping D. halts the progression of the abortion

A. ensures passage of all the products of conception Rationale: Misoprostol is used to stimulate uterine contractions and evacuate the uterus after an abortion to ensure passage of all the products of conception. Rho(D) immune globulin is used to suppress the immune response and prevent isoimmunization.

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called? A. external cephalic version B. vaginal manipulation C. external rotation D. internal rotation

A. external cephalic version Rationale: External cephalic version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect? A. gestational trophoblastic disease B. hyperemesis gravidarum C. pregnancy-induced depression D. placenta previa

A. gestational trophoblastic disease Rationale: This client has risk factors of a "molar" pregnancy: nausea and vomiting at an early gestational week and dark brown vaginal discharge. The early nausea/vomiting can be due to a high hCG level, which is a sign of gestational trophoblastic disease. There is only one sign/symptom of hyperemesis gravidarum. Placenta previa is marked by bright red bleeding and tends to happen later in gestation. There are no data to support any psychosis at this stage.

A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as: A. hydatidiform mole. B. placenta accrete. C. ectopic pregnancy. D. hydramnios.

A. hydatidiform mole. Rationale: Gestational trophoblastic disease comprises a spectrum of neoplastic disorders that originate in the placenta. The two most common types are hydatidiform mole (partial or complete) and choriocarcinoma. Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid. Ectopic pregnancy, placenta accreta, and hydramnios fall into different categories of potential pregnancy complications.

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client? A. hypotonic contractions B. uncoordinated contractions C. hypertonic contractions D. Braxton Hicks contractions

A. hypotonic contractions Rationale: With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

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 inversion C. uterine atony D. hematoma

A. laceration Rationale: 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.

A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia? A. magnesium sulfate B. nifedipine C. betamethasone D. indomethacin

A. magnesium sulfate Rationale: The drug used to relax the uterine muscles and for seizure prophylaxis is magnesium sulfate. Betamethasone promotes fetal lung maturity, indomethacin inhibits uterine activity to arrest preterm labor nifedipine blocks calcium movement into the muscle cells and inhibits preterm labor

A nursing student correctly identifies the most desirable position to promote an easy birth as which position? A. occiput anterior B. shoulder dystocia C. face and brow D. breech

A. occiput anterior Rationale: Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of: A. postpartum depression. B. Lack of partner support C. postpartum blues. D. maladjustment to parenting.

A. postpartum depression Rationale: Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation.

A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out? A. prevent maternal D antibody formation. B. promote maternal D antibody formation. C. prevent fetal Rh blood formation. D. stimulate maternal D immune antigens.

A. prevent maternal D antibody formation. Rationale: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.

A nurse is preparing to administer vitamin K to a newborn who was just birthed vaginally. Which site would be appropriate for the nurse to select? A. vastus lateralis B. ventrogluteal C. dorsogluteal D. deltoid

A. vastus lateralis Rationale: The nurse would select an injection site on the vastus lateralis (anterior lateral aspect of the thigh) muscle. The deltoid, ventrogluteal, or dorsogluteal would be inappropriate to use.

The nurse assesses the newborn baby boy at 4 hours of age. Which set of vital signs requires no additional action? A. T- 36.8C, HR-126, RR-42 B. T-36.3C, HR- 146, RR- 52 C. T- 36.9C, HR-156, RR-82 C. T- 36.8C, HR- 186, RR-62

A. ·T- 36.8C, HR-126, RR-42 Rationale: The infant's temperature should be between 36.5-37.2C The expected range for heart rate is 110-160 beats per minutes The expected respiratory rate is 40-60 breaths per minutes

Nasal flaring in the newborn infant is an expected finding True or False?

False Rationale: In the newborn, nasal flaring indicates the infant is experiencing a problem with transition to extrauterine life.

A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess? A. increased fetal movement B. "knife-like" abdominal pain with vaginal bleeding C. generalized vasospasm D. painless bright red vaginal bleeding

B. "knife-like" abdominal pain with vaginal bleeding Rationale: The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placentae.

A woman arrives in the L & D unit in the beginning early phase with her contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the woman in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the woman for which priority assessment caused by a rapid birth? A. Assess the woman's breathing and intervene if necessary. B. Check perineal area frequently for bleeding. C. Assess bladder for fullness. D. Assess and administer pain medication as needed.

B. Check the perineal area frequently for bleeding Rationale: Precipitous dilation (dilatation) is cervical dilation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara. Contractions can be so forceful they lead to premature separation of the placenta or lacerations of the perineum, placing the woman at risk for hemorrhage. The other interventions are appropriate, but the priority is assessing for bleeding/hemorrhage.

During the initial newborn assessment of the baby boy, how does the nurse assess nasal patency? A. Insert a suction catheter and monitor oxygen saturation level B. Close mouth, occlude one nostril, and observe respirations. C. Occlude both nostrils and observe for mouth breathing. D. Measure oxygen saturation level and auscultate breath sounds

B. Close mouth, occlude one nostril, and observe respirations Rationale: Babies are nose breathers. If the nares are not patent, the infant will demonstrate respiratory distress when the other nares are occluded. This distress is caused by a condition called choanal atresia.

A prenatal ultrasound reveals that a pregnant client has vasa previa. Which action by the nurse is appropriate? A. Expect that an oxytocin infusion will be needed to augment labor. B. Explain to the client about the need for a scheduled cesarean birth. C. Tell the client to come to the labor and birth suite as soon as labor begins. D. Anticipate the need for the use of forceps during the birth process.

B. Explain to the client about the need for a scheduled cesarean birth. Rationale: In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and, therefore, deliver before the fetus. The vessels may tear with cervical dilation (dilatation), just as a placenta previa may tear. Tearing would result in sudden fetal blood loss. Therefore, if the vasa previa is identified prenatally on ultrasound, a cesarean birth is scheduled prior to full term to prevent risks of spontaneous labor. Waiting until labor begins would increase the pregnant client's risk for vessel tearing. Neither oxytocin nor forceps would be used.

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 tetracycline. B. Instill 0.5% ophthalmic erythromycin. C. Instill 0.5% ophthalmic silver nitrate. D. Watch for signs of eye irritation.

B. Instill 0.5% ophthalmic erythromycin. Rationale: 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 nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? A. Monitor the client's beta-hCG level. B. Monitor the client's vital signs and bleeding. C. Monitor the fetal heart rate (FHR). D. Monitor the mass with transvaginal ultrasound.

B. Monitor the client's vital signs and bleeding Rationale: A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending spontaneous abortion (miscarriage). Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.

Newborns who are small for gestational age have fetal growth restriction True or False?

False Rationale: Small for gestational age (SGA) describes newborns weighing less than 2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero or birth weight at or below the 10th percentile as correlated with the number of weeks of gestation. These infants are constitutionally small, but otherwise healthy. Fetal growth restriction is the pathologic counterpart to SGA.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to: A. assess her vaginally for full dilation (dilatation). B. assess the rate of flow of the oxytocin infusion. C. instruct her to breathe in and out rapidly. D. administer oral orange juice for added potassium.

B. assess the rate of flow of the oxytocin infusion Rationale: A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

A woman who is 42 weeks' pregnant comes to the clinic. During the visit, which assessment should the nurse prioritize? A. measuring the height of the fundus B. determining an accurate gestational age C. checking for spontaneous rupture of membranes D. asking her about the occurrence of contractions

B. determining an accurate gestational age Rationale: Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia A. pendulous abdomen B. diabetes C. nullipara D. preterm birth

B. diabetes Rationale: Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

On an Apgar evaluation, how is reflex irritability tested? A. raising the infant's head and letting it fall back B. flicking the soles of the feet and observing the response C. dorsiflexing a foot against pressure resistance D. tightly flexing the infant's trunk and then releasing it

B. flicking the soles of the feet and observing the response Rationale: Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

A nurse is preparing a presentation about the changes in the various body systems during the postpartum period and their effects for a group of new mothers. The nurse explains which event as influencing a postpartum woman's ability to void? Select all that apply A. use of an opioid anesthetic during labor B. generalized swelling of the perineum C. decreased bladder tone from regional anesthesia D. use of oxytocin to augment labor E. need for an episiotomy

B. generalized swelling of the perineum C. decreased bladder tone from regional anesthesia d. use of oxytocin to augment labor Rationale: Many woman gave difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment their labor (antidiuretic effect). These women will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. In addition, urination may be impeded by perennial lacerations generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus; hematomas; decreased bladder tone as a result of regional anesthesia; and diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition? A. hemorrhage B. macrosomia C. infection D. dystocia

B. macrosomia Rationale: Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, cephalopelvic disproportion, uteroplacental insufficiency, meconium aspiration, and intrauterine infection. Amniotic fluid volume begins to decline by 40 weeks' gestation, possibly leading to oligohydramnios. Hemorrhage, infection, and dystocia pose a risk to the mother, not the fetus.

During a routine prenatal visit, a client is found to have 1+ proteinuria and a blood pressure rise to 140/90 mm Hg with mild facial edema. The nurse recognizes that the client has which condition? A. eclampsia B. preeclampsia without severe features C. preeclampsia with severe features D. gestational hypertension

B. preeclampsia without severe features Rationale: A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. If a seizure from gestational hypertension occurs, a woman has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to have preeclampsia without severe features when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart and mild facial or extremity edema. A woman has progressed to preeclampsia with severe features when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. A woman has passed into eclampsia when cerebral edema is so acute a tonic-clonic seizure or coma has occurred.

The nursing student demonstrates an understanding of dystocia with which statement? A. "Dystocia is not diagnosed until after the birth." B. "Dystocia is diagnosed at the start of labor." C. "Dystocia cannot be diagnosed until just before birth." D. "Dystocia is diagnosed after labor has progressed for a time."

D. "Dystocia is diagnosed after labor has progressed for a time." Rationale: Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

The infant of a diabetic mother usually experiences hyperglycemia after birth. True or False?

False Rationale: The infant of a diabetic mother is at risk for hypoglycemia after birth due to its prolonged hyperinsulin state

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh: A. 3,500 g to 4000 g B. 2500 to 3000 g C. 4,000 g to 4500 g D. 3,000 g to 3500 g

C. 4,000 g to 4500 g Rationale: Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.1 to 9.9 lb) or more at birth, complicates approximately 10% of all pregnancies The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

During pregnancy a woman's blood volume increases to accommodate the growing fetus to the point that vital signs may remain within normal range without showing signs of shock until the woman has lost what percentage of her blood volume? A. 20% B. 30% C. 40% D. 50%

C. 40% Rationale: Vital signs can be within normal range, even with significant blood loss, because a pregnant woman can lose up to 40% of her total blood volume without showing signs of shock.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? A. Shortness of breath is a common adverse effect of the medication. B. Avoid iron replacement therapy. C. Avoid over-the-counter (OTC) salicylates D. Wear knee-high stockings when possible.

C. Avoid over-the-counter (OTC) salicylates. Rationale: Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism

A woman who is positive for hepatitis B has just given birth to a newborn. What precaution(s) will the nurse take in caring for the mother and newborn? Select all that apply. A. Give the mother a one-time dose of hepatitis B immunoglobulin within 12 hours after the birth. B. Admit the newborn to the hospital for several extra days for additional IV medications to treat the infection. C. Bathe the newborn thoroughly soon after birth to remove maternal blood. D. Give the newborn the HBV vaccination within 12 hours after birth. E. Tell the mother that to not not breastfeed the newborn due to the infection.

C. Bathe the newborn thoroughly soon after birth to remove maternal blood. D. Give the newborn the HBV vaccination within 12 hours after birth. Rationale: A mother who is positive for hepatitis B runs a high risk of transmitting the disease to the newborns, if the newborn is not treated immediately and precautions taken. Bathing immediately after birth is one precaution. Additionally, the newborn will receive the HBV vaccination along with a one-time dose of hepatitis B immunoglobulin within 12 hours of birth.

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? A. Assess the baby's temperature. B. Assess for pain source. C. Check blood glucose. D. Place child in a radiant warmer.

C. Check blood glucose. Rationale: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia? A. McRonald maneuver B. McGeorge maneuver C. McRoberts maneuver D. McDonald maneuver

C. McRoberts maneuver Rationale: McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina? A. Place the client in Trendelenburg position and gently attempt to reinsert the cord. B. Contact the health care provider and prepare the client for an emergent vaginal birth. C. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. D. With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders.

C. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. Rationale: The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the fetus off the cord to ensure its safety. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, which can result in the presenting part compressing the cord, cutting off oxygen and nutrients to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and cannot attempt to reinsert the cord. A vaginal birth is contraindicated in this situation.

A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for? A. ABO incompatibility B. HELLP syndrome C. Twin-to-twin transfusion syndrome (TTTS) D. TORCH syndrome

C. Twin-to-twin transfusion syndrome (TTTS) Rationale: When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur.

When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation? A. deep red, fleshy -smelling lochia B. voiding of 350cc C. blood pressure 90/50 mm Hg D. profuse sweating

C. blood pressure 90/50 mm Hg Rationale: In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood pressure and cardiac output are not expected changes during the postpartum period. Early identification is essential to ensure prompt intervention. Depp red, fleshy smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate problem, but 350cc is appropriate Profuse sweating is a normal finding during postpartum period

A client has arrived to the birthing center in labor, requesting a VBAC. After reading the client's previous history, the nurse anticipates that the client would be a good candidate based on which finding? A. had prior classic uterine incision B. had prior transfundal uterine surgery C. had previous lower abdominal incision D. has a contracted pelvis

C. had previous lower abdominal incision Rationale: The choice of a vaginal or repeat cesarean birth can be offered to women who have had a lower abdominal incision. Contraindications to VBAC include a prior classic uterine incision, prior transfundal uterine surgery, uterine scar other than low-transverse ("bikini cut") cesarean scar, contracted pelvis, and inadequate staff at the facility if an emergency cesarean birth is required.

A nurse is reviewing the medical record of a pregnant client. The physical exam reveals that the placenta is implanted near the internal os but does not reach it. The nurse interprets this as which condition? A. placenta percreta B. placenta increta C. low-lying placenta D. placenta accreta

C. low-lying placenta Rationale: Placenta previa is currently classified with two terms: "placenta previa" and "low-lying placenta." If the placental edge is less than 2 cm from the internal os but does not cover it, the placenta is reported as low-lying. If the placental edge covers the internal os, it is labeled as a placenta previa. Placenta accreta spectrum includes three conditions. Accreta is the most common and is a condition in which the placenta attaches itself too deeply into the wall of the uterus but does not penetrate the uterine muscle. Placenta increta occurs when the placenta invades the myometrium, and placenta percreta occurs when it has extended through the myometrium and uterine serosa and adjacent tissue.

The mother of a newborn asks the nurse, "What are these small red marks on the back of my baby's neck and between the eyes? They seem to more visible when my baby is crying." The nurse would describe this finding as which skin variation? A. nevus flammeus B. vernix C. salmon patches D. milia

C. salmon patches Rationale: Stork bites or salmon patches are superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and upper lip. They are caused by a concentration of immature blood vessels and are most visible when the newborn is crying. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. They may also appear on the chin and forehead. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. Nevus flammeus, also called a port-wine stain, commonly appears on the newborn's face or other body areas. It is a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is purple-red.

A pregnant client at 28 weeks' gestation in preterm labor has received a dose of betamethasone IM today at 1400. The client is scheduled to receive a second dose. At which time would the nurse expect to administer that dose? A. today at 2200 B. tomorrow at 1800 C. tomorrow at 1400 D. tomorrow at 0800 E. tomorrow at 1200

C. tomorrow at 1400 Rationale: Betamethasone is given as two intramuscular injections, given 24 hours apart. Because the woman got her first dose at 1400 today, then her second dose would be given at 1400 tomorrow. Corticosteroids given to the mother in preterm labor can help prevent or reduce the frequency and severity of respiratory distress syndrome in premature infants delivered between 24 and 34 weeks' gestation.

A client with a pendulous abdomen and uterine fibroids (uterine myomas) has just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? A. occipitoposterior position B. anterior fetal position C. transverse lie D. cephalic presentation

C. transverse lie Rationale: A transverse lie, in which the fetus is more horizontal than vertical, occurs in the following instances: women with pendulous abdomens; uterine fibroids (uterine myomas) that obstruct the lower uterine segment; contraction of the pelvic brim; congenital abnormalities of the uterus; or hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelvis.

A nurse is caring for a pregnant client admitted with mild preeclampsia. Which assessment finding should the nurse prioritize? A. proteinuria of 200 mg/24 hours B. mild hand edema C. urine output of less than 15 ml/hr D. 1+ ankle edema

C. urine output of less than 15 ml/hr Rationale: Severe preeclampsia may develop suddenly and bring with it high blood pressure of more than 160/110 mm Hg, proteinuria of more than 500 mg in 24 hours, oliguria of less than 15 ml/hr, cerebral and visual symptoms, and rapid weight gain. Mild facial edema or hand edema occurs with mild preeclampsia. A urinary output of 15 ml/hr would result in an output of 360 ml/24 hours, which would be below the recommended range and should be reported. Ankle edema of 1+ could be related to regular pregnancy and not necessarily just severe preeclampsia. A finding of 3+ to 4+ pitting edema would be more alarming and require intervention.

Which complication is most likely responsible for a late postpartum hemorrhage? A. perineal laceration B. cervical laceration C. uterine subinvolution D. clotting deficiency

C. uterine subinvolution Rationale: Late postpartum bleeding is usually the result of subinvolution of the uterus. Retained products of conception or infection commonly cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may have an immediate postpartum hemorrhage if the deficiency is not corrected at the time of birth.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: A. increase her intravenous fluid infusion rate. B. put firm pressure on the fundus of her uterus. C. tell the woman to take short, catchy breaths. D. administer oxygen by mask.

D. administer oxygen by mask Rationale: An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

______________ involves the transfer of heat from one object to another when the two are in direct contact with each other.

Conduction

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means? A. "His testicles have not descended into the scrotal sac." B. "He has normal male genitalia." C. "He has fluid in the scrotal sac." D. "The opening of his urethra in located on the under surface of the tip of the penis."

D. "The opening of his urethra in located on the under surface of the tip of the penis." Rationale: The term "hypospadias" refers to the urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis). There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule? A. 2 cm/hour for cervical dilation B. 1/4 cm/hour for cervical dilation C. 1/2 cm/hour for cervical dilation D. 1 cm/hour for cervical dilation

D. 1 cm/hour for cervical dilation Rationale: In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? A. 36 hours before the infant is discharged home with its parents B. When the infant is 48 hours old C. Just before discharge home D. 24 hours after the newborn's first protein feeding

D. 24 hours after the newborn's first protein feeding Rationale: The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

A nurse is monitoring the serum drug level of a pregnant client with preeclampsia who is receiving a continuous infusion of magnesium sulfate. For which level would the nurse continue the infusion? A. 10.6 mg/100 ml B. 9.2 mg/100 ml C. 8.4 mg/100 ml D. 6.8 mg/100ml

D. 6.8 mg/100ml Rationale: Therapeutic serum blood levels for magnesium sulfate should be maintained at 5-8 mg/100 ml. If blood serum levels rise above this, respiratory depression, cardiac arrhythmias, and cardiac arrest can occur.

A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize? A. Weight gain of 1.2 lb (0.54 kg) during the past 1 week B. A systolic blood pressure increase of 10 mm Hg C. Pedal edema D. A dipstick value of 2+ for protein

D. A dipstick value of 2+ for protein Rationale: The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in a majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was.

The nurse assesses the placement of the baby's ears. How does the nurse assess this? A. An imaginary line is drawn through the inner and outer canthi of the eyes, intersecting the lower lobes of the ear. B. The distance from the tip of the nose to the earlobe to the outer canthi of the eyes is measured C. The occipitofrontal circumference is compared to the head circumference measured over the level of the ear canal D. An imaginary line is drawn from the inner and outer canthi of the eyes, reaching to top notch of ears at the junction with the scalp

D. An imaginary line is drawn from the inner and outer canthi of the eyes, reaching to top notch of ears at the junction with the scalp Rationale: The relationship of the ears to the eyes, using an imaginary line between the inner and outer canthus of the eyes, reaching to top notch of the ears at the junction with the scalp, is used to assess ear placement. Low set ears do not intersect this line and may be a sign of a genetic condition

The nurse is preparing discharge instructions for a client who has developed endometritis after a cesarean birth. As the client is to be discharged on antibiotic therapy, which instruction should the nurse prioritize? A. Proper perineal care B. Get plenty of sleep C. Complete the antibiotic course D. Hand washing

D. Hand washing Rationale: Handwashing is the best defense against the spread of infections. The client is at a higher risk of developing further infections due to her current situation; handwashing before and after using the restroom and doing perineal care will help prevent an infection from occurring. It will also be important for the woman to wash her hands to ensure the infection is not passed to her infant or other family members. The other options of completing the antibiotics, completing proper perineal care, and getting plenty of rest are also important but not a priority.

The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true? A. Mild decelerations B. Early decelerations C. Variable decelerations D. Late decelerations

D. Late decelerations Rationale: When the fetus is being deprived of oxygen the fetus will demonstrate late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.

A nurse is providing care to four breastfed newborns who are being monitored for hyperbilirubinemia. When assessing each newborn's indirect bilirubin level, the nurse would notify the health care provider about which newborn? A. Newborn A: 1-day-old newborn with bilirubin level of 2 mg/dl (34.32 µmol/l) B. Newborn C: 36-hour-old newborn with a bilirubin level of 10 mg/dl (171.04 µmol/l) C. Newborn B: 2-day-old newborn with bilirubin level of 6 mg/dl (102.62 µmol/l) D. Newborn D: 48-hour-old newborn with bilirubin level of 14 mg/dl (239.46 µmol/l)

D. Neworn D: 48-hour-old newborn with bilirubin level of 14 mg/dl (239.46 µmol/l) Rationale: There is no set level at which indirect serum bilirubin requires treatment because other factors, such as age, maturity, and breastfeeding status, affect this determination. However, if the level rises to more than 10 to 12 mg/dl (171.04 to 205.25 µmol/l), treatment is usually considered. Therefore, because Newborn D has a level of 14 mg/dl (239.46 µmol/l), treatment is most likely. Newborn C's level is at the lower end of this range, so treatment may or may not be initiated. Newborns A and B have levels below the range cited.

A client at 25 weeks' gestation presents with a blood pressure of 152/99 mm Hg, pulse 78 beats/min, no edema, and urine negative for protein. What would the nurse do next? A. Assess the client for ketonuria B. Provide health education C. Document the client's blood pressure D. Notify the health care provider

D. Notify the health care provider Rationale: The client is exhibiting a sign of gestational hypertension, elevated blood pressure greater than or equal to 140/90 mm Hg that develops for the first time during pregnancy. The health care provider should be notified to assess the client. Without the presence of edema or protein in the urine, the client does not have preeclampsia.

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? A. Check deep tendon reflexes. B. Measure fundal height. C. Obtain a voided urine specimen and determine blood type. D. Palpate the fundus and check fetal heart rate.

D. Palpate the fundus and check fetal heart rate. Rationale: The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.

The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record? A. Prolonged labor B. Prodromal labor C. False labor D. Precipitous labor

D. Precipitous labor Rationale: A labor that is less than 3 hours in duration is a precipitous labor. Prolonged labor, also known as failure to progress, occurs when labor lasts for approximately 20 hours or more in a first-time mother. Prodromal labor is labor that starts and stops before fully active labor begins. The contractions are real, but they come and go, and labor does not progress. False labor is intermittent nonproductive or practice contractions, which most commonly occur in the last 2 months before a full-term delivery.

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation? A. Preterm labor that was undiagnosed B. Placenta previa obstructing the cervix C. Possible fetal death or injury D. Premature separation of the placenta

D. Premature separation of the placenta Rationale: Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.

The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client? A. Prepare to assist the care provider with an amniotomy. B. Administer an analgesic to the client. C. Prepare for a precipitous vaginal birth. D. Prepare the client for a cesarean birth.

D. Prepare the client for a cesarean birth. Rationale: If a transverse lie persists, the fetus cannot be born vaginally. Thus, the nurse will prepare the client for a caesarean birth. There is no indication the client will have precipitous labor. Amniotomy, artificial rupture of the membranes, is not indicated when preparing from a caesarean birth. The nurse would not administer analgesic before surgery unless prescribed by the health care provider.

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? A. Suction the mouth and then the nose with a suction catheter. B. Place the newborn on its stomach with the head down and gently pat its back. C. Suction the nose first and then the mouth with a bulb syringe. D. Using a bulb syringe, suction the mouth then the nose.

D. Using a bulb syringe, suction the mouth then the nose. Rationale: A bulb syringe is used initially to suction secretions from a newborn's mouth and nose, starting with the mouth so the newborn does not aspirate the mucus into its lungs. Suctioning the nose first may stimulate the newborn to gasp or cry and this may lead to aspiration. A suction catheter is only used if the bulb syringe cannot manage all the secretions. Patting the newborn on the back will not clear out all the oral secretions.

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? A. Placenta previa B. Umbilical cord compression C. Hypertonic uterus D. Uterine rupture

D. Uterine rupture Rationale: The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

The nurse is providing an in-service education program to a group of home health care nurses who provide care to postpartum women. After teaching the group about the process of involution, the nurse determines that additional teaching is needed when the group identifies which process as being involved? A. Catabolism B. muscle fiber contraction C. epithelial regeneration D. vasodilation

D. Vasodilation Rationale: Involution involves three retrogressive processes: contraction of muscle fibers to reduce those previously stretched during pregnancy; catabolism which reduces enlarged myometrial cells; and regeneration of uterine epithelium from the lower layer of the deciduas after the upper layers have been sloughed off and shed during lochial discharge. Vasodilation is not involved.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention? A. artificial rupture of membranes B. a cesarean birth C. a precipitous birth D. a forceps and vacuum-assisted birth

D. a forceps and vacuum-assisted birth Rationale: A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? A. administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) B. administration of platelet transfusions as prescribed C. continual firm massage of the uterus D. avoiding administration of oxytocics

D. administration of platelet transfusions as prescribed Rationale: When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho(D) are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth? A. assess for cleft palate B. monitor for a cardiac anomaly C. extensive lacerations D. brachial plexus assessment

D. brachial plexus assessment Rationale: The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia, which should be assessed and treated. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case? A. administration of morphine sulfate B. darkening room lights and decreasing noise and stimulation C. administration of oxytocin D. cesarean birth

D. cesarean birth Rationale: If the cause of the delay in dilation (dilatation) is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD.

A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client? A. complications of preterm labor B. placental abruption (abruptio placentae) C. complications of placenta previa D. complications of a post-term pregnancy

D. complications of a post-term pregnancy Rationale: A post-term pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.

A nurse is caring for a pregnant client whose fetus has been diagnosed with macrosomia. When reviewing the client's history, which information would the nurse expect to find? A. small body size of mother B. preterm pregnancy C. maternal rickets D. gestational diabetes

D. gestational diabetes Rationale: Macrosomia usually results from uncontrolled gestational diabetes, genetic problems, multiparity, or postterm pregnancy. Preterm pregnancy, small body size of mother, and maternal rickets are not associated with macrosomia. Small body size and maternal rickets are associated with pelvic contraction at the inlet.

The nurse is assessing a client at 12 weeks' gestation at a routine prenatal visit who reports something doesn't feel right. Which assessment findings should the nurse prioritize? A. vaginal bleeding, increased hPL levels B. visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen C. elevated hCG levels, enlarged abdomen, quickening D. gestational hypertension, hyperemesis gravidarum, absence of FHR

D. gestational hypertension, hyperemesis gravidarum, absence of FHR Rationale: The early development of gestational hypertension/preeclampsia, hyperemesis gravidarum, and the absence of FHR are suspicious for gestational trophoblastic disease. The elevated levels of hCG lead to the severe morning sickness. There is no fetus, so FHR, quickening, and evidence of a fetal skeleton would not be seen. The abdominal enlargement is greater than expected for pregnancy dates, but hCG, not hPL, levels are increased.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? A. postpartum blues B. postpartum panic disorder C. postpartum depression D. postpartum psychosis

D. postpartum psychosis Rationale: The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? A. decreased respiratory rate B. elevated blood pressure C. warm and flushed skin D. weak and rapid pulse

D. weak and rapid pulse Rationale: The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider as soon as possible.

Cephalohematoma usually requires surgical correction True or False?

False Rationale: Cephalohematoma resolves gradually over 2 to 3 weeks without treatment.

The nurse assesses the baby for jaundice, a common condition in newborns. Identify which characteristics are associated with physiologic jaundice and which are associated with pathologic jaundice. A. Limited to neonates B. Results from increased hemolysis of red blood cells C. Occurs across the lifespan D. Results from interruption of bilirubin metabolism E. Jaundice may appear at <24 hours of age F. Jaundice appears between 48 and 72 hours of age

Physiologic jaundice A. Limited to neonates B. Results from increased hemolysis of red blood cells F. Jaundice appears between 48-72 hours of age Pathologic jaundice C. Occurs across the lifespan D. Results from interruption of bilirubin metabolism E. Jaundice may appear at <24 hours of age Rationale: Physiologic jaundice is a condition seen in newborns. Because the liver is immature, it is unable to clear the bilirubin from the normal hemolysis of red blood cells, so jaundice results. Jaundice appears between 48-72 hours of age. Pathologic jaundice is an interruption of bilirubin metabolism. In the newborn, pathologic jaundice may appear during the first day of life. Risk factors for pathologic jaundice include prematurity, sepsis, acidosis, or blood type incompatibilities. Symptoms of pathologic jaundice include lethargy, high pitched crying, and poor feeding.

One maternal factor increasing the chance of bearing a large-for-gestational-age newborn is being postterm. True or False?

True Rationale: Maternal factors increasing the chance of bearing an LGA newborn include diabetes mellitus or glucose intolerance, genetics, gestational weight gain, male fetus, maternal obesity, multiparity, paternal height, postterm gestation, and prior history of a macrosomic infant.