NUR 403 Exam 2 Prep EAQs
A nurse is caring for a postpartum client. Where does the nurse expect the fundus to be located if involution is progressing as expected 12 hours after birth? 2 cm below the umbilicus 3 cm above the umbilicus 1 cm above the umbilicus 3 cm below the umbilicus
1 cm above the umbilicus Rationale Twelve hours after birth, the uterus is 1 cm above the umbilicus, and each succeeding day it descends one fingerbreadth. Therefore the uterus should be 2 cm below the umbilicus on the second postpartum day. A uterus 3 cm above the umbilicus indicates that the bladder is full. The uterus is 3 cm below the umbilicus on the fourth postpartum day because the uterus descends one fingerbreadth per day.
Prolonged labor is an incident very common in pregnant adolescents. Which age group of adolescents has the highest risk of prolonged labor? 12 to 13 years 14 to 15 years 16 to 18 years 19 to 21 years
12 to 13 years Rationale The adolescents of age group 12 to 13 years are at the higher risk of prolonged labor because of cephalopelvic disproportion and underdevelopment. The age group of 14 to 15 will have moderate chances of prolonged labor as the transition between cephalopelvic disproportion and pelvic adequacy starts. For age group 16 to 21 the labor time shortens as the body completes transition.
A client in labor at 39 weeks' gestation is told by the primary healthcare provider that she will require a cesarean delivery. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth? Gonorrhea Chlamydia Chronic hepatitis Active genital herpes
Active genital herpes Rationale Once the membranes have ruptured, the active herpes infection ascends and can infect the fetus; because herpes does not cross the placenta, a cesarean birth prevents transfer of the virus to the fetus. Gonorrhea, Chlamydia, and chronic hepatitis are not indications for a cesarean birth; treatment is pharmacologic.
When the fetal head begins to crown during an emergency precipitous birth, how should the nurse respond? Pressing firmly on the fundus Applying gentle perineal pressure Encouraging the client to push forcefully Telling the client to take prolonged deep breaths
Applying gentle perineal pressure Rationale Applying gentle perineal pressure prevents too-rapid expulsion of the head, which can lead to perineal laceration in the mother. Pressing firmly on the fundus is contraindicated; a precipitate birth is caused by forceful uterine contractions that expel uterine contents. Pushing may cause too-rapid expulsion and perineal laceration. At this time the urge to push is uncontrollable; the client will be unable to take prolonged deep breaths.
What is the priority nursing intervention during the first 2 hours after a cesarean birth? Evaluating fluid needs to maintain optimum hydration Monitoring the incision to help prevent the onset of infection Encouraging bonding to promote mother-infant interaction Assessing the lochia to identify the complication of hemorrhage
Assessing the lochia to identify the complication of hemorrhage Rationale The amount and character of the lochia must be checked after a cesarean birth just as they are after a vaginal birth. Although it is important to maintain hydration, preventing hemorrhage is the priority. Although the area of the incision is monitored for signs of hemorrhage, it is too early for evidence of infection. Bonding is an important consideration after the conditions of both mother and newborn have stabilized.
How does the nurse distinguish true labor from false labor? Cervical dilation is evident. Contractions stop when the client walks around. The client's contractions progress only when she is in a side-lying position. Contractions occur immediately after the membranes rupture.
Cervical dilation is evident Rationale Progressive cervical dilation is the most accurate indication of true labor. With true labor, contractions will increase with activity. Contractions of true labor persist in any position. Contractions may not begin until 24 to 48 hours after the membranes rupture.
A multigravida client has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time? In the pelvic cavity Just below the xiphoid process At the umbilicus and in the right quadrant Halfway between the symphysis pubis and the umbilicus
Halfway between the symphysis pubis and the umbilicus Rationale Immediately after birth the fundus is palpated midway between the symphysis pubis and the umbilicus. The gradual descent of the uterus into the pelvic cavity takes about 2 weeks after the birth. The fundus is never elevated to the level of the xiphoid process. The fundus will not have reached the level of the umbilicus until 1 hour after birth; when the uterus is deviated to the right, it usually indicates bladder distention.
The nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Small breast buds Wrinkled thin skin Multiple sole creases Presence of scrotal rugae Pinnae that remain flat when folded
Small breast buds Wrinkled thin skin Pinnae that remain flat when folded Rationale Breast buds are small, with underdeveloped nipples, in the preterm infant. Preterm newborns have little subcutaneous fat; the skin is wrinkled, and blood vessels and bony structures are visible. Preterm infants' ears contain little cartilage and are very inelastic when folded; at term, the ears contain cartilage, and the pinnae are firm. Sole creases develop progressively during pregnancy and cover the entire foot at term. A preterm male infant's testes are undescended; rugae develop progressively and cover the entire scrotum of the full-term male newborn.
Five minutes after a birth the nurse determines that the client's placenta is separating. Which clinical finding indicates placental separation? Uterine fundus relaxes Umbilical cord lengthens Abdominal pain becomes severe Vaginal seepage of blood is continuous
Umbilical cord lengthens Rationale As the placenta separates and descends down the uterus, the cord descends down the vaginal canal and therefore appears to lengthen. The fundus contracts and becomes rounded and firmer. The client may feel a contraction; however, it is not as uncomfortable as the painful contractions at the end of the first stage of labor. Continual seepage occurs in the presence of hemorrhage; a sudden large gush of blood heralds placental separation.
A client gives birth vaginally to an infant who weighs 8 lb, 13 oz (3997 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vagina and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain? Full bladder Vaginal hematoma Infected episiotomy Enlarged hemorrhoids
Vaginal hematoma Rationale A vaginal hematoma caused by fetal head pressure during the birthing process can result in severe pain. Bladder distention causes abdominal, not perineal, discomfort. Although the episiotomy may cause pain, it should not be excruciating; it is too early for an infection to have developed. Although hemorrhoids may cause perineal discomfort, they should not cause the vagina to feel full and heavy.
The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping due to afterbirth pains? Multipara who has vaginally delivered three children Primipara whose newborn weighed 7 lb Multipara with effectively controlled diabetes Multipara whose second child was small for gestational age
Multipara who has vaginally delivered three children Rationale A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara's uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara is. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.
A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. What does the nurse conclude? Infection is present Cesarean birth is necessary Precipitate birth is imminent The fetus may be compromised in utero
The fetus may be compromised in utero Rationale Greenish-brown amniotic fluid is a sign of meconium in utero, which may indicate that the fetus is compromised. There is not enough information to determine that infection is present. If the fetal heart rate becomes nonreassuring, a cesarean birth will help ensure a viable newborn. Meconium-stained amniotic fluid is not an indication of imminent birth during the latent phase of labor.
Which finding indicates that a newborn has vernix caseosa? Brown hair on the skin Rosy to yellowish skin Light-pink to reddish-brown skin Cheese-like substance on the skin
Cheese-like substance on the skin Rationale Sebum and desquamating cells on the newborn's skin give it a white, cheesy appearance, which is called vernix caseosa. Brown hair on a newborn's skin is called lanugo. Newborns of Asian descent will have rosy to yellowish skin. Light-pink to reddish-brown skin indicates that the newborn is of Native-American (Indigenous) descent.
What complications are associated with excessive weight gain during pregnancy in adolescents? Fetal anemia Preterm labor Cesarean delivery Maternal mortality Postpartum obesity
Preterm labor Cesarean delivery Postpartum obesity Rationale Excessive weight gain during pregnancy is associated with such complications of labor and delivery as preterm labor and cesarean delivery. It is also linked with postpartum obesity and its associated health risks. Excessive weight gain during pregnancy is associated with maternal (not fetal) anemia and infant (not maternal) mortality.
A client in labor is admitted with a suspected breech presentation. Which occurrence should the nurse be prepared for? Uterine inertia Prolapsed cord Imminent birth Precipitate labor
Prolapsed cord Rationale The feet or buttocks do not block the cervical opening effectively. The cord may slip through the cervix and become compressed. This is a life-threatening event for the fetus. Uterine inertia may result from fatigue or cephalopelvic disproportion; it is not related to fetal position. When a fetus is in the breech presentation the labor is usually long and difficult. Rapid dilation and precipitate labor may occur with fetuses in the cephalic position as well as the breech position.
Which reflex does the nurse assess in a newborn to determine auditory ability? Startle reflex Rooting reflex Glabellar reflex Extrusion reflex
Startle reflex Rationale To assess auditory ability in a newborn, the nurse makes a sudden loud sound, which causes the newborn's arms to abduct. This is called the startle reflex. When assessing the rooting reflex, the nurse strokes the child's cheek, and the child's head turns to the same side in response. When assessing the glabellar reflex, the nurse taps the tip of the child's nose, and the child's eyes close in response. When assessing the extrusion reflex, the nurse touches the child's tongue, and the child forces it out in response. The rooting reflex, glabellar reflex, and extrusion reflex do not help determine auditory ability.
Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion? Facial redness and an urge to push Bulging perineum, crowning, and caput Less intense, less frequent contractions Increased bloody show, irritability, and shaking
Increased bloody show, irritability and shaking Rationale Increased bloody show, irritability, and shaking are some of the classic signs of the transition phase of the first stage of labor. The increase in bloody show is related to the complete dilation of the cervix, the irritability is related to the intensity of contractions, and the shaking is believed to be a vasomotor response. Facial redness and an urge to push are associated with the start of the second stage of labor. A bulging perineum, crowning, and caput signal that birth is imminent. Less intense, less frequent contractions may signal uterine hypotonicity, which may occur throughout the first stage of labor.
The nurse is assessing a 12-hour-old newborn. Which clinical finding should be reported to the health care provider in a timely manner? Jaundice Cephalhematoma Erythema toxicum Edematous genitalia
Jaundice Rationale Jaundice occurring in the first 24 hours of life is pathological; it is associated with Rh or another blood incompatibility. Cephalhematoma is a collection of blood between the skull and periosteum that does not cross the suture line; it resolves within 6 weeks, and although it should be documented it does not require treatment. Erythema toxicum is newborn dermatitis, believed to be an inflammatory response. The rash is harmless, and although it should be documented it does not require treatment. Edematous genitalia, a response to maternal hormones, are common in newborns.
During labor an internal fetal monitor is applied. Which fetal heart rate (FHR) should most concern the nurse? One that does not slow during contractions One that ranges from 130 to 140 beats/min One that drops to 110 beats/min during a contraction One that returns to baseline after a contraction ends
One that returns to baseline after a contraction ends Rationale A return of the FHR to baseline after a contraction ends is called a late deceleration; it begins after the contraction has started, the lowest point of the deceleration occurs after the peak of the contraction, and the deceleration usually does not return to baseline until after the contraction ends (late recovery). Late decelerations, which are caused by uteroplacental insufficiency, are a sign of a compromised fetus. The FHR does not always drop with a contraction. Beat-to-beat variability indicates a fetus with a healthy nervous system and does not warrant concern. A decrease in fetal heart rate to 110 beats/min during a contraction, known as an early deceleration, is the result of fetal head compression during a contraction; the FHR returns to baseline at the same time that the contraction ends.
While assessing a client during the fourth stage of labor a nurse notes that the perineal pad is soaked end to end with approximately 75 mL of lochia rubra. What is the priority nursing action? Palpating the uterine fundus Documenting the amount and type of lochia Accompanying the client to the bathroom to empty her bladder Calling the laboratory to test the hemoglobin and hematocrit levels
Palpating the uterine fundus Rationale The fundus should be palpated to determine whether it is boggy. A boggy uterus reflects uterine atony; it should be massaged until firm. Documenting the amount of lochia without correcting the problem will place the client in physical jeopardy, because the client may hemorrhage. Although a full bladder decreases uterine contractility and should be emptied, allowing the client to ambulate to the bathroom to void before massaging her fundus may result in increased bleeding. Requesting laboratory tests without first intervening will place the client in physical jeopardy, because the client may hemorrhage.
The nurse is assessing a newborn immediately after birth. Which finding indicates normal development? A body weight of 3500 g Blood pressure of 70/60 mm Hg A core body temperature of 96° F (35.6° C) Head circumference 3 cm less than chest circumference
A body weight of 3500 g Rationale The newborn has a body weight of 3500 g, which is within the normal range of 2700 to 4000 g. Therefore this indicates normal development. The core body temperature of the newborn is 96° F (35.6° C), which is less than the normal range of 97.7° F to 99.7° F (36.5° C to 37.6° C). Therefore the core body temperature of 96° F (35.6° C) indicates hypothermia. The normal blood pressure of a newborn on the first day of birth is 65/45 mm Hg. A blood pressure finding of 70/60 mm Hg indicates very high blood pressure. The head circumference of the newborn is less than the chest circumference, which indicates that the newborn may have microcephaly.
A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" Which information should the nurse provide to the patient at this time? The cervix dilates and becomes effaced in true labor. Bloody show is the first sign of true labor. The membranes rupture at the beginning of true labor. Fetal movements lessen and become weaker in true labor.
The cervix dilates and becomes effaced in true labor Rationale The major difference between true and false labor is that true labor can be confirmed by the presence of dilation and effacement of the cervix. Bloody show may occur before or after true labor begins. The membranes may rupture before or after labor begins. Fetal movements continue unchanged throughout labor.
The nurse is caring for a client in labor. Which assessment finding reveals that the transition phase of labor has probably begun? The client assumes the lithotomy position. The frequency of contractions decreases. The client complains of back and perineal pain. The client begins to perspire and has a flushed face.
The client begins to perspire and has a flushed face. Rationale As cervical dilation nears completion, labor is intensified, resulting in an increase in energy expenditure; this increase manifests in perspiration and a flushed face. The client is usually restless and thrashes about during transition, assuming no particular position. Pain is increased because contractions are more frequent and intense, and they last longer. Back pain usually indicates a posterior-lying position of the fetus's head. Perineal pain starts during the second stage of labor.
When assessing a neonate immediately after birth, the nurse observes an inability to close the eyes completely. The nurse also observes drooping of the corner of the neonate's mouth, and the absence of wrinkling of the forehead and nasolabial fold. What does the nurse infer from these findings? The neonate has bleeding in the subgaleal layer from labor. The neonate's cranial nerve V was pressurized during labor. The neonate's cranial nerve VII was pressurized during labor. The neonate was exposed to vaginal gonorrheal infection during labor.
The neonate's cranial nerve VII was pressurized during labor Rationale Inability to close the eyes completely, drooping of the corner of mouth, and absence of wrinkling of the forehead and nasolabial fold indicate facial paralysis. When the facial nerve, or cranial nerve VII, is pressurized during labor, it can result in facial paralysis. Bleeding in the subgaleal layer indicates subgaleal hemorrhage in a neonate. Subgaleal hemorrhage is not characterized by inability to close the eyes, drooping of the corner of mouth, or absence of wrinkling of the forehead and nasolabial fold. Cranial nerve V does not innervate the face, so damage to cranial V does not result in facial paralysis. A neonate who is exposed to vaginal gonorrheal infections during labor may develop ophthalmia neonatorum, not facial paralysis.
Thirty minutes after a client gives birth, the nurse palpates the client's uterus. It is relaxed and the lochia is excessive. What is the nurse's initial action? Check vital signs. Massage the uterus. Notify the practitioner. Elevate the foot of the bed.
Massage the uterus Rationale Massaging the uterus will induce uterine contraction and cause expulsion of clots; frequent massage should be continued to keep the uterus firm and inhibit bleeding. Pulse and blood pressure do not change significantly unless large amounts of blood are lost. If bleeding continues after the fundus is massaged, the practitioner should be notified. Placing the client in the Trendelenburg position is appropriate if the client is in shock, but the data do not indicate shock.
The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding? Most important is diagnosis within 2 days after birth Most important is the institution of a corrective formula soon after birth It depends on whether phenylpyruvic acid is found in the urine 1 week after birth It depends on the level of phenylalanine found in the blood immediately after birth
Most important is the institution of a corrective formula soon after birth Rationale Adherence to a diet low in phenylalanine is necessary for optimal physical growth and little or no adverse effect on mental development; a restricted diet that is instituted late will not reverse brain damage. Detection cannot occur until the infant has taken milk or formula that contains phenylalanine for 24 hours and metabolites have accumulated in the blood. All newborns are now screened for the presence of metabolic disorders prior to discharge from hospital. Behaviors indicating mental retardation and central nervous system involvement are usually evident by about 6 months of age in the untreated infant. Phenylpyruvic acid in the urine is an intermediate product of the metabolism of phenylalanine in the body. It is related to compliance with the prescribed diet after the diagnosis is made. There is no phenylalanine in the blood at birth; it first becomes measurable after the infant ingests milk or formula.
A mother asks the neonatal nurse why her infant must be monitored so closely for hypoglycemia when her type 1 diabetes was in excellent control during the entire pregnancy. How should the nurse best respond? "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."
"Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop." Rationale The infant of a diabetic mother (IDM) produces a higher level of insulin in response to the increased maternal glucose level; after birth it takes several hours for the newborn to adjust to the loss of the maternal glucose. A healthy newborn's glucose level does not drop significantly after birth. A newborn's pancreas usually produces more insulin as a response to the maternal glucose level, but this response is not specific to the IDM. IDMs have the same glucose stores as other newborns; their responses to the loss of maternal glucose levels differ.
A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate? "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." "Breast milk is easily digested; giving your infant a little rice cereal will keep him full longer." "It sounds as though your baby is a little spoiled; try to resist feeding more often than every 4 hours." "You may not be producing enough milk; it'll be important for you to supplement feedings with formula."
"It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." Rationale Newborns typically nurse every 2 to 3 hours. Although breast milk is easily digested, feeding solids to an infant is not recommended at this age. Feeding satisfies a fundamental need; one does not spoil an infant by nursing as needed. Adequate intake is evidenced in infant weight gain and adequate urinary and bowel elimination. Supplementing feedings with formula may lead to decreased milk production.
While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? Recording these expected findings Obtaining an order for an oxytocic medication Asking the client when she last changed the perineal pad Notifying the primary healthcare provider that the client may be hemorrhaging
Asking the client when she last changed the perineal pad Rationale The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported or recorded without additional information. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus. The vital signs do not indicate hemorrhage; further assessment is needed before the nurse comes to this conclusion.
A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect? Hypovolemia Hypoglycemia Hypercalcemia Hypothyroidism
Hypoglycemia Rationale SGA infants may exhibit signs of hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. Decreased blood pressure, pallor with cyanosis, tachycardia, retractions, lethargy, and a weak cry are signs of hypovolemia. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.
Which nursing action promotes psychosocial development for a newborn? Washing hands prior to holding the newborn Measuring the newborn using an approved length board Weighing the newborn on the same scale during hospitalization Placing the newborn in the mother's arms during the first hour of life
Placing the newborn in the mother's arms during the first hour of life Rationale Placing a newborn in the mother's arms for the first hour of life is a nursing action that promotes psychosocial development, in the form of bonding with his or her mother. Washing hands prior to holding the newborn is hospital policy and promotes infection prevention and control. Measuring the newborn's length using an approved length board and weighing the newborn on the same scale each day during hospitalization allows the nurse to assess newborn growth.
A registered nurse is teaching a nursing student about structural factors that affect labor in adolescents. Which statements by the nursing student indicate effective learning? "Fetopelvic incompatibility results from the teenager's smaller stature." "Twelve-year-old girls generally have labors that are shorter than older women's." "Cephalopelvic disproportion is the main reason for cesarean births in adolescents." "Prolonged labor in an adolescent aged 13 years is the result of fetopelvic incompatibility." "The transition from pelvic disproportion to pelvic adequacy usually occurs around age 18."
"Fetopelvic incompatibility results from the teenager's smaller stature." "Cephalopelvic disproportion is the main reason for cesarean births in adolescents." "Prolonged labor in an adolescent aged 13 years is the result of fetopelvic incompatibility." Rationale Fetopelvic incompatibility is a reflection of the teenager's smaller stature and incomplete growth process. Young adolescents have the highest rate of cesarean births, primarily because of cephalopelvic disproportion. Labor may be prolonged in these clients as a direct result of fetopelvic incompatibility. Older adolescent girls (15 to 21 years), especially those who have previously delivered babies, have shorter-then-average labors. The transition from pelvic disproportion to pelvic adequacy occurs around 15 years of age in the average adolescent girl.
A woman in labor hears the primary healthcare provider tell the nurse that the fetal lie is longitudinal. The mother asks the nurse what this means in relation to her labor and birth of the baby. How should the nurse respond? "A vaginal birth is possible." "We're anticipating a cesarean delivery." "It has no relevance to the labor and birth." "Labor probably will be long, and you might have back pain."
A vaginal birth is possible Rationale A longitudinal lie means that the fetus is lying parallel to the woman's spine; therefore vaginal birth is possible. A transverse, not longitudinal, lie might indicate that vaginal birth is unlikely, and cesarean birth is anticipated. The fetal lie will influence the labor and the birth of the fetus. A longitudinal lie does not indicate that the labor will be prolonged; however, if the fetal head is in the posterior occiput position, second-stage labor may be prolonged, accompanied by back pain.
A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include? Assessing respirations, keeping him warm, and identifying him Applying an antibiotic to the eyes, administering vitamin K, and bathing him Aspirating the oropharynx, rushing him to the nursery, and stimulating him often Weighing him, placing him in a crib, and waiting until the mother is ready to hold him
Assessing respirations, keeping him warm, and identifying him Rationale Establishing a patent airway, diminishing cold stress, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.
A client who has had a cesarean birth appears upset. She has been having difficulty breastfeeding for two days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action? Obtaining the requested formula Administering the prescribed pain medication Assessing the client's breastfeeding technique Notifying the practitioner of the client's request to switch feeding methods
Assessing the client's breastfeeding technique Rationale The nurse should assess the client to determine why she is having difficulty with breastfeeding. She may be uncomfortable or in need of assistance with her breastfeeding technique. Immediately providing the formula without assessing the situation does not meet the client's needs at this time. Pain may be a factor in the client's frustration with breastfeeding; however, this should be determined through the assessment process. Notifying the practitioner of the client's request to switch feeding methods is premature. It is the nurse's responsibility to assess the situation and arrive at a solution in collaboration with the client.
A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider regarding breech presentations when caring for this client? Severe back discomfort will occur. Length of labor usually is shortened. Cesarean birth probably will be necessary. Meconium in the amniotic fluid is a sign of fetal hypoxia.
Cesarean birth probably will be necessary. Rationale A cesarean birth may be performed when the fetus is in the breech presentation because the risk of morbidity and mortality is increased. A vertex presentation in the occiput posterior position usually causes back pain. Labor is usually longer with a fetus in the breech presentation because the buttocks are not as effective as the head as a dilating wedge. Meconium is a common finding in the amniotic fluid of a client whose fetus is in a breech presentation, because contractions compress the fetal intestinal tract, causing release of meconium.
A client in active labor is admitted to the birthing room. A vaginal examination reveals that her cervix is dilated 6 to 7 cm. In light of this finding, what does the nurse expect? Client may experience nausea and vomiting. Client's bloody show will become more profuse. Client will experience uncontrollable shaking of her legs. Client's contractions will become longer and more frequent.
Client's contractions will become longer and more frequent. Rationale This is an accurate description of contractions as labor progresses through the active portion of the first stage of labor. Nausea and vomiting occurs in the transition phase of the first stage of labor. More profuse bloody show and uncontrollable shaking of the legs occur in the transition phase of the first stage of labor.
A man calls the prenatal clinic to ask the nurse when he should bring his wife to the hospital. He says, "The baby is due in 2 weeks, but she thinks it could be earlier. This is our first baby, and we're nervous." The nurse knows that as a nullipara, it would be important for the client to be seen if the contractions do what? Decrease when the client walks Are irregular and vary in intensity Come every 5 minutes for an hour Come every 10 minutes for an hour
Come every 5 minutes for an hour Rationale Contractions every 5 minutes apart for 1 hour are an indication of true labor. Because the woman is a nullipara, this is an appropriate response. Contractions that ease when the client walks or are irregular and vary in intensity are signs of false labor. Contractions coming 10 minutes apart for 1 hour in a nullipara are too far apart for true labor. This reading would be appropriate for a multiparous woman, whose labor is likely to be shorter and more intense.
A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which signs of postmaturity does the nurse identify? Cracked and peeling skin Long scalp hair and fingernails Red, puffy appearance of face and neck Vernix caseosa covering the back and buttocks Creases covering the neonate's full soles and palms
Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms Rationale Dry, peeling skin is related to decreased vernix and prolonged immersion in amniotic fluid. Abundant scalp hair and long fingernails are characteristics of postmaturity. These findings are typically noted in a term newborn who is 2 to 3 weeks old. Creases on the entire soles and palms are typical of full-term maturity; preterm newborns have few sole and palm creases. A red, puffy appearance of the face and neck is not a sign of postmaturity; neonates born to diabetic mothers usually have this appearance. Vernix is found on a newborn at about 38 weeks' gestation and disappears after 40 weeks' gestation.
When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? Decreased blood pressure Increased oral temperature Diminished peripheral pulses Unequal bilateral breath sounds
Decreased blood pressure Rationale The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects.
While caring for a pregnant client with a body mass index of 32 during labor, the nurse observes that the second stage of labor lasts for about 11 minutes. The nurse also finds that the expected birth weight of the fetus is around 4200 g. Which complication does the nurse anticipate in the neonate after birth? Erb palsy Klumpke palsy Strawberry hemangioma Erythema toxicum neonatorum
Erb palsy Rationale Maternal body mass index of greater than 30, a second stage of labor lasting less than 15 minutes, and an infant birth weight higher than 4000 g indicates a risk of Erb palsy or Erb-Duchenne paralysis in the neonate. Klumpke palsy can result from severe stretching of the upper extremities while the trunk is relatively less mobile during labor. A maternal body mass index greater than 30, a second stage of labor lasting less than 15 minutes, and infant birth weight higher than 4000 g are not the indicators of strawberry hemangioma or erythema toxicum neonatorum.
After a spontaneous vaginal delivery the client expresses concern when the newborn is brought to her after being cleaned and examined, regarding a red rash with small papules on the face, chest, and back. What condition does the nurse recognize? Harlequin sign Vernix caseosa Nevus flammeus Erythema toxicum
Erythema toxicum Rationale Erythema toxicum is a benign, generalized, transient rash that is a reaction to the new environment in which a neonate finds itself. It disappears a short time after birth. It is not the harlequin sign, which is dilation of blood vessels on one side of the body with red skin on one side, and white skin on the other. It is not vernix caseosa, which is a thick, white, greasy substance that protects the skin in utero. It is not nevus flammeus, or port wine stain, a reddish-purple capillary angioma below the dermis.
An infant is born precipitously in the emergency department. What should the nurse's initial action be? Tie and cut the umbilical cord Establish an airway for the newborn Ascertain the condition of the uterine fundus Arrange transport for mother and infant to the birthing unit
Establish an airway for the newborn Rationale The nurse should position the newborn with the head slightly lower than the chest to allow mucus to flow by gravity and then rub the back to stimulate crying, which promotes oxygenation. Tying and cutting the umbilical cord are not the priority; there is no need for haste in cutting the cord. Ascertaining the condition of the uterine fundus is not the priority; the uterus still contains the placenta and will not contract. Arranging transport for mother and infant to the birthing unit is not the priority; the well-being of the newborn and mother must be confirmed before they are moved.
The nurse is providing care to a multiparous client in active labor. The client is requesting something for the pain. What is the nurse's priority intervention? Examining the client's cervix for dilation and effacement Determining the client's options by assessing the prescriptions in the chart Asking her whether she prefers an epidural or something in her intravenous line Evaluating the fetal monitoring strip to determine the frequency and duration of contractions
Examining the client's cervix for dilation and effacement Rationale Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia. Assessment is the initial step of the nursing process. Options for pain management would be determined after dilation has been assessed. The client may be asked about her preferred method of analgesia, but that should be done after her degree of dilation has been determined. The stem of the question indicated that the client is in active labor; information on the fetal monitoring strip regarding contractions will not add to the assessment data.
The nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor has this client reached? First Latent Second Transitional
First Rationale The first stage of labor lasts from the onset of contractions until the cervix is fully dilated at 10 cm. The client is in the early phase of the first stage of labor. There is no latent stage of labor. The second stage of labor lasts from complete dilation to birth. There is no transitional stage of labor; transition is the last phase of the first stage of labor.
The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. How should contractions be timed? From the end of one contraction to the end of the next contraction From the end of one contraction to the beginning of the next contraction From the beginning of one contraction to the end of the next contraction From the beginning of one contraction to the beginning of the next contraction
From the beginning of one contraction to the beginning of the next contraction Rationale The frequency of contractions is timed from the beginning of one contraction to the beginning of the next; this is the definition of one contraction cycle. The beginning, not the end, of a contraction is the starting point for timing the frequency of contractions. The time between the end of one contraction and the beginning of the next contraction is the interval between contractions. Timing from the beginning of one contraction to the end of the next contraction is too long a timeframe and will produce inaccurate information.
While caring for a client during labor, what does the nurse remember about the second stage of labor? It ends at the time of birth. It ends as the placenta is expelled. = It begins with the transition phase of labor. It begins with the onset of strong contractions.
It ends at the time of birth Rationale The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.
After an uneventful pregnancy a client at term arrives at the birthing unit. The nurse determines that her contractions are 10 minutes apart and that her cervix is dilated 2 cm. What stage of labor should the nurse document in the client's medical record? Second stage Latent first stage Active first stage Transition stage
Latent first stage Rationale Regular contractions occurring 10 minutes apart with a cervix dilated 2 cm indicate that the client is in the latent phase of the first stage of labor. The second stage of labor begins with full dilation and ends with expulsion of the fetus. Contractions occur more regularly and more frequently and the cervix is more dilated in the active stage of labor. Contractions are intense and occur every 1 to 2 minutes in the transition phase of the first stage of labor.
The nurse is assessing a new mother at a healthcare facility. Which symptom does the nurse identify as a risk factor for postpartum blues? Frantic energy Mild irritability Hallucinations Unwillingness to sleep
Mild irritability Rationale Postpartum blues are transient symptoms that a client may experience after childbirth. About 85% of women experience postpartum blues with symptoms of mild irritability, tearfulness, rapid mood fluctuations, and anxiety. About 0.1% to 0.2% of postpartum women experience postpartum psychosis. Frantic energy, hallucinations, and unwillingness to sleep are clinical manifestations of postpartum psychosis.
During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented? Stork bites Forceps marks Mongolian spots Ecchymotic areas
Mongolian spots Rationale Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.
The nurse is assessing several postpartum clients at the very beginning of her shift. Which problem does the nurse identify that might predispose a client to postpartum hemorrhage? Preeclampsia Multifetal pregnancy Prolonged first-stage labor Cephalopelvic disproportion
Multifetal pregnancy Rationale The presence of more than one fetus overdistends the uterus, which may result in uterine atony and thus postpartum hemorrhage. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage.
After the birth of her child, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. Why is this necessary?" How should the nurse respond? "Your baby needs the injection to promote development of red blood cells." "An injection of vitamin K will help keep your baby from becoming jaundiced." "Newborns are deficient in vitamin K. This treatment will ensure adequate levels." "A newborn's blood clots extremely rapidly. This injection will help decrease the clotting time."
Newborns are deficient in vitamin K. This treatment will ensure adequate levels. Rationale The absence of intestinal flora in the newborn results in a low level of vitamin K, causing a transient blood coagulation deficiency; for this reason an injection of vitamin K is given prophylactically on the day of birth. Vitamin K has no effect on erythropoiesis. Vitamin K is important for the synthesis of the clotting factor in the liver, but it will not prevent jaundice. Newborns have a blood coagulation deficiency; the blood clots more slowly, not more quickly.
The primary healthcare provider determines that a fetus is in a breech presentation. Which complication should the nurse monitor this client for? Rapid dilation of the cervix, indicating precipitate labor Stronger contractions, indicating progression of the labor Nonreassuring fetal signs, indicating prolapse of the cord Cessation of contractions, indicating primary uterine inertia
Nonreassuring fetal signs, indicating prolapse of the cord Rationale The feet or buttocks are not effective in blocking the cervical opening, and the cord may slip through and become compressed. Rapid dilation and precipitate labor are more likely to occur if the fetus is in a cephalic presentation. Stronger contractions, indicating progression of labor, are an expected occurrence. Uterine inertia may result from fatigue or cephalopelvic disproportion and is not related directly to fetal presentation.
After an assessment of a male newborn, the nurse suspects postmaturity. Which observations help confirm this conclusion? Profuse scalp hair Parchmentlike skin Abundant vernix caseosa Few rugae over the scrotum Creases covering the entire soles
Profuse scalp hair Parchmentlike skin Creases covering the entire soles Rationale Profuse scalp hair is associated with a postterm newborn. As the fetus matures, usually the hair on the scalp becomes more profuse. Parchmentlike skin is associated with a postterm newborn. Skin desquamation occurs as a result of prolonged exposure to amniotic fluid, causing cracking, peeling, and drying of skin and resulting in a parchmentlike appearance. Creases will cover the entire sole of each foot if the newborn is full term or postterm; preterm newborns have an absence of or few skin creases on the soles of the feet. Abundant vernix caseosa is associated with a preterm newborn. Postterm newborns exhibit little vernix caseosa. Immature genitals (e.g., undescended testes, small scrotum, few rugae over the scrotum) are associated with a preterm newborn. As the fetus reaches full term and beyond, both testes usually descend, and rugae cover the scrotal sac.
An infant born at 36 weeks' gestation weighs 4 lb, 3 oz (1899 g) and has Apgar scores of 7 and 9. Which nursing actions will be performed upon the infant's admission to the nursery? Recording of vital signs Administration of oxygen Offering a bottle of dextrose in water Evaluation of the neonate's health status Supportive measures to keep the neonate's body temperature stable
Recording of vital signs Evaluation of the neonate's health status Supportive measures to keep the neonate's body temperature stable Rationale Recording of vital signs is an important part of recordkeeping for all newborns. All newborns are evaluated on their admission to the nursery. All newborns should be kept warm to maintain a stable body temperature. The neonate's Apgar scores (7 and 9) do not indicate a need for oxygen. Newborns are either breast-fed or fed formula; glucose water is not offered first.
A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, "I can't take this a minute longer." What does this behavior indicate to the nurse caring for her? There was no preparation for labor. She should receive an analgesic for pain. She is entering the transition phase of labor. Hypertonic uterine contractions are developing.
She is entering the transition phase of labor Rationale The contractions become stronger, last longer, and occur erratically during the transition phase; the intervals between contractions become shorter than the contractions themselves; the client needs to apply a great deal of concentration and effort to pace her breathing with each contraction. Even clients who have been adequately prepared will experience these behaviors during the transition phase of the first stage of labor. Administration of an analgesic at this time may reduce the effectiveness of labor and depress the fetus. There is no indication that the contractions are hypertonic.
When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? There is a slow rate of involution. There are retained placental fragments. The bladder has become overdistended. The uterine ligaments are overstretched
The bladder has become overdistended Rationale A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contractions and uterine descent into the pelvis. If retained placental fragments were present, the uterus would be boggy in addition to being displaced, and vaginal bleeding would be heavy. From this assessment the nurse cannot make a judgment regarding overstretched uterine ligaments.
The nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? The newborn has a flat abdomen. The newborn weighs 6 lbs (2,700 g). The newborn's hands and feet appear cyanosed. The newborn does not blink in the presence of light. The circumference of the head is 33 cm (13 in).
The newborn weighs 6 lbs (2,700 g). The newborn's hands and feet appear cyanosed. The circumference of the head is 33 cm (13 in). Rationale The average newborn weighs between six to nine pounds (2,700 to 4,000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13 to 14 inches). Newborns generally have protuberant (not flat) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye.
The nurse is caring for a primigravid client during labor. Which physiologic finding does the nurse observe that indicates birth is about to take place? Bloody discharge from the vagina is increasing. The perineum has begun to bulge with each contraction. The client becomes irritable and stops following instructions. Contractions occur more frequently, are stronger, and last longer.
The perineum has begun to bulge with each contraction Rationale The bulging perineum indicates that the fetal head is on the pelvic floor and birth is imminent. An increase in bloody show and an increasingly irritable client are seen during the transition phase or at the beginning of the second stage. Contractions occurring more frequently that are stronger and last longer are part of the progress of labor, not a sign that birth is imminent.