NUR 4410 OB Exam 2 PrepU
A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?
Ensure the baby empties the breasts at each feeding
A nurse is preparing an in-service education program for a group of nurses about dystocia involving problems with the passenger. Which problem would the nurse likely include as the most common?
persistent occiput posterior position
The Ballard scoring system evaluates newborns on which two factors?
physical maturity and neuromuscular maturity
When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because:
these measurements may not change until after the blood loss is large.
The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next?
Check for bladder distention, while encouraging the client to void.
The nurse is assessing a 35-year-old woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dl (8.10 mmol/L), hemoglobin 13 g/dl (130 g/L), and hematocrit 37% (0.37). Based on these results, which instruction should the nurse prioritize?
check blood sugar levels daily
A nurse is transporting a neonate from the nursery to the mother's room. The nurse ensures that the neonate is moved in a warmed isolette to prevent heat loss by which mechanism?
convection
Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns?
"Breastfed babies need supplements of glucose water to help lower bilirubin levels."
During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status?
6 to 8 weeks after pregnancy
The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history reveals gestational hypertension. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored?
Jitteriness and irritability
The nurse assesses the client who is 1 hour postpartum and discovers a heavy, steady gush of bright red blood from the vagina in the presence of a firm fundus. Which potential cause should the nurse question and report to the RN or primary care provider?
Laceration
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?
3 months
A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus (GBS) infection in the client who is at:
36 weeks' gestation.
A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which cause when responding to the new mother?
insufficient calorie intake
A laboring woman is receiving oxytocin IV to augment her labor and 2 hours later begins having contractions every 2 minutes lasting 60 to 90 seconds each with little, if any, rest time in between the contractions. At this time, which interventions would be the priority for the nurse caring for this client? Select all that apply. - administer betamethasone - ask the woman to drink 32oz water - discontinue oxytocin - administer IV bolus of fluids - apply O2 via mask at 8-10 L/min
- discontinue oxytocin - administer IV bolus of fluids - apply O2 via mask at 8-10 L/min
A client has been admitted to the hospital with a diagnosis of severe preeclampsia. Which nursing intervention is the priority?
Confine the client to bed rest in a darkened room.
A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase?
"It sounded like you had quite a time getting here. Would you like to continue your story?"
A woman in active labor has just had her membranes ruptured to speed up labor. The nurse is concerned the woman is experiencing a prolapse of the umbilical cord when the nurse notices which pattern on the fetal heart monitor?
variable deceleration pattern
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?
"Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain."
The nurse is admitting to the floor a woman who just gave birth. What medical and pregnancy history would the labor and delivery nurse include in the report?
Maternal blood type
A nurse is preparing to administer erythromycin ointment to a 1-hour-old newborn. What will the nurse do first?
Review the health care provider's order.
The infant has Apgar scores of 7 at 1 minute and 9 at 5 minutes. What is the indication of this assessment finding?
adjusting to extrauterine life
Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a woman who presents with preterm premature rupture of membranes (PPROM) has completed how many weeks of gestation?
less than 37 weeks
The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which description?
light
A nurse is assessing a client's lochia every 15 minutes for the first hour during the fourth stage of labor. Which finding would the nurse expect to assess?
moderate lochia rubra with a fleshy odor
A pregnant client with severe preeclampsia has developed HELLP syndrome. In addition to the observations necessary for preeclampsia, what other nursing intervention is critical for this client?
observation for bleeding
A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience?
postpartum baby blues
The nurse is assessing a client at a postpartum visit. Which hemodynamic change will the nurse expect the client to exhibit?
rise in hematocrit
When dealing with a pregnant adolescent, the nurse assists the client to integrate the tasks of pregnancy while at the same time fostering development of which trait?
self-identity
A nurse is caring for a pregnant client admitted with mild preeclampsia. Which assessment finding should the nurse prioritize?
urine output of less than 15 ml/hr
A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase?
taking-in phase
Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type?
third-degree laceration
A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation?
transition to mastery
A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client?
uterine atony
A nurse is conducting a refresher program for a group of nurses returning to work in the newborn clinic. The nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional education is needed when the group identifies which parameter as being included in the assessment?
blood pressure
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?
external cephalic version
A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?
hemorrhage
A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate?
"Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy."
A nurse suspects that a pregnant client may be experiencing a placental abruption (abruptio placentae) based on assessment of which finding? Select all that apply. - dark red vaginal bleeding - insidious onset - absence of pain - rigid uterus - absent fetal heart tones
- dark red vaginal bleeding - rigid uterus - absent fetal heart tones
The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply. - nasal flaring - RR 64/min - bluish coloration of hands and feet - chest retractions - HR 120 bpm
- nasal flaring - RR 64/min - chest retractions
A client is admitted to the unit in preterm labor. In preparing the client for this therapy, the nurse anticipates that the client's pregnancy may be prolonged for how long when this therapy is used?
2 to 7 days
The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately?
Dyspnea
A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client?
Lab work will be drawn to rule out acid-base imbalances.
The nurse is working with several clients who have recently delivered healthy newborns. Which statement by a mother would alert the nurse to further assess the mother for postpartum depression?
"I seem to cry more each and every day that goes by."
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?
McRoberts maneuver
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?
Monitor the client's vital signs and bleeding.
A nurse is providing discharge instructions to a postpartum client. Which symptom is a possible complication that the nurse should educate the client about?
Notify the health care provider of increased lochia and bright red bleeding.
The nurse understands the need to be aware of the potential of bleeding disorders in pregnant clients. Which disorder should she be aware of that occurs in the second trimester?
Placenta previa
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."
The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics?
Ask her questions and observe her caring for the baby.
The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?
Bladder distention
The nurse is monitoring a woman who is receiving IV oxytocin to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin?
Discontinue the oxytocin infusion.
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize?
Document normal findings.
The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met?
Promote early breastfeeding for the infants.
The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for placental abruption (abruptio placentae). Which assessment finding should the nurse prioritize?
Sharp fundal pain and discomfort between contractions
A nurse is providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching?
She is at increased risk for type 2 diabetes mellitus after her baby is born.
A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate?
Stop the infusion immediately.
A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding?
The client states, "He has my eyes and nose."
The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values?
The health care provider needs to be notified of the latest lab values.
The nurse is examining a newborn and notes that there is swelling on the newborn's head, limited to the right side of the head. How should the nurse interpret this finding?
This is a cephalohematoma and will spontaneously resolve without interventions
The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client?
administrating a selective serotonin reuptake inhibitor
A nurse is assessing a newborn's vital signs 2 hours after birth. The newborn had low Apgar scores at birth. Which finding would lead the nurse to notify the health care provider?
pulse rate 100 bpm
A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
recurrent pelvic infections
During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?
the taking-hold phase
While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?
yellowish white
A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately?
1+ deep tendon reflexes
A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine the effectiveness of therapy?
Assess deep tendon reflexes.
The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize?
Assess the Rh of the baby.
A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression? Select all that apply. - restlessness - feelings of worthlessness - feeling overwhelmed - sleeping well - hunger
- restlessness - feelings of worthlessness - feeling overwhelmed
A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client?
"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color."
A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student makes which statement?
"The baby takes the first breath when ready to leave the uterus."
A newborn is 7 minutes old. Her heart rate is 92 bpm, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score?
5
A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?
Immediate surgery
A pregnant woman is being evaluated for HELLP. The nurse reviews the client's diagnostic test results. An elevation in which result would the nurse interpret as helping to confirm this diagnosis?
LDH
A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect?
firm, rigid uterus on palpation
A primigravida at 28 weeks' gestation comes to the clinic for a checkup. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with preterm birth would the nurse discuss with the client? Select all that apply. - hx of previous preterm birth - current multiple gestation pregnancy - large-for-gestational-age fetus - uterine or cervical abnormalities - previous c-section
- hx of previous preterm birth - current multiple gestation pregnancy - uterine or cervical abnormalities
A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much?
25 to 50 ml
A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result?
6.1 mEq/L
A nurse is caring for a client with hyperemesis gravidarum. Which nursing action is the priority for this client?
Administer IV normal saline with vitamins and electrolytes.
A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation?
Decreased fetal oxygenation
The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?
Palpate her fundus.
The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving betamethasone and magnesium sulfate. The nurse will continue to monitor this client for which condition?
Severe preeclampsia
A woman is experiencing a postpartum hemorrhage due to uterine atony. Which risk factor would the nurse recognize as contributory to this specific problem?
multiparity
Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client?
temperature of 38°C (100.4°F) or higher after the first 24 hours after birth
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?
postpartum psychosis
A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth?
brachial plexus assessment
When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?
massaging the fundus firmly
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?
low-lying placenta
A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period? a. sits and rocks infant for long intervals b. eager to talk about her birth experience c. has not asked for anything for pain all day d. did her perineal care independently
d
