OB Exam 2 Review Questions

A nurse is explaining the various methods of pain control used during labor and birth. When explaining why general anesthesia is rarely used, which information would the nurse include? Select all that apply.

A pregnant woman has a risk of vomiting and aspiration General anesthesia readily crosses the placenta (Common complications include fetal depression, uterine relaxation, and potential maternal vomiting and aspiration.)

At which time is it most important to monitor for umbilical cord prolapse?

After rupture of membranes

Which occurs as a result of contraction decrement? Select all that apply.

Fetal heart rate should return to baseline Blood flow to the fetus improves

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer?

On the uterine fundus (The nurse is correct to place the tocodynamometer on the fundus with the sensor facing downward and then strap it securely to the abdomen.)

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?

Third (Stage three begins with the birth of the baby and ends with delivery of the placenta.)

A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure?

To prevent supine hypotension syndrome

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication?

Uterine atony

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply.

milia acrocyanosis lanugo on the back

Which factor might result in a decreased supply of breast milk in a postpartum client?

supplemental feedings with formula

A nurse is teaching a woman in her third trimester about Braxton Hicks contractions. When describing these contractions, which information would the nurse likely include? Select all that apply.

"They often spread downward before they go away." "They usually feel like a tightening across the top of your uterus" "They go away when you walk around or change position."

A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply.

Possible experience of fluctuations in sexual interest Use of a water based lubricant to ease vaginal discomfort Possibility of increased breast sensitivity during sexual activity

A primigravida has an office appointment at 39 weeks' gestation. Which assessment data is *most* definitive of the onset of labor?

Cervical ripening is noted on examination

During the fourth stage of labor, which mother typically experiences the strongest afterpains?

A multipara who is breast feeding (Afterpains are variable contractions which occur after birth of the newborn and delivery of the placenta. These afterpains occur in the recovery phase. In general, afterpains are more noticeable for the multipara, not a primigravid, who is a breast-feeding mother.)

Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority?

Blood pressure (Once the epidural catheter is inserted, blood pressure readings are obtained by the nurse every 3 to 5 minutes due to the potential side effect of hypotension.)

When palpating for fundal height on a postpartum woman, which technique is preferable?

Placing one hand at the base of the uterus, one on the fundus

What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply.

Temp of 101.8 Fundal height level of one fingerbreadth above the umbilicus

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?

Uterine atony

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

Uterine infection Prolonged labor Hydramnios

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk?

increase in red blood cell production

Which suggestion by the nurse about pushing would be most appropriate to a woman in the second stage of labor?

"Choose whatever method you feel most comfortable with for pushing"

Which assessment findings indicate a distressed fetus? Select all that apply.

Absent accelerations Late deceleration patterns Persistent bradycardia

The nurse is assessing a client for rupture of membranes. Which findings would confirm the presence of ruptured membranes? Select all that apply.

Nitrazine paper turns blue Ferning is present A pool of fluid is visible in the vagina

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." (When the baby's umbilical cord is clamped, the baby takes the first breath and the lungs begin to function. The breath usually occurs when the baby is stimulated by a slight slap. The baby takes the first breath within 10 seconds post birth, not when ready to leave the uterus.)

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?

6.5

Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH?

7.2

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?

Continue to massage the client's fundus

A nurse is preparing a class on newborn adaptations for a group of soon-to-be parents. When describing the change from fetal to newborn circulation, which information would the nurse include? Select all that apply.

Decrease in right atrial pressure leads to closure of the foramen ovale. Onset of respirations leads to a decrease in pulmonary vascular resistance. Increase in pressure in the left atrium results from increases in pulmonary blood flow. Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply.

Edema Slight bruising

A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension?

Ephedrine (given to elevate BP)

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 bpm. The nurse is aware that which factors can result in fetal tachycardia? Select all that apply.

Fetal distress Fetal movement Maternal fever Uteroplacental insufficiency

The nurse is monitoring a client at 38 weeks' gestation who is bleeding. Which assessment findings indicate the client is hemodynamically unstable? Select all that apply.

Fetal heart rate 198 bpm Urine output 20 mL/hr

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

Fetal heart rate declining late with contractions and remaining depressed (Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.)

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply.

History of diabetes Hemoglobin level 10 mg/dL Placenta requiring manual extraction (Risk factors for postpartum infection include history of diabetes, labor over 24 hours, hemoglobin less than 10.5 mg/dL, prolonged rupture of membranes (more than 24 hours), and manual extraction of the placenta.)

The nurse is preparing a client for an epidural block. Which intervention is a priority before the epidural anesthesia is started?

IV fluid bolus

There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?

It can be administered by the nurse

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which action would the nurse include in the discussion as possible strategies for the new mothers to do? Select all that apply.

Performing kegel exercises Avoiding smoking Losing weight if obese

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply.

Rounded mass over symphysis pubis Dullness on percussion over symphysis pubis Fundus boggy to the right of the umbilicus

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring?

The client who is very restless and is moving around in the bed (The client who is restless and frequently changing positions is more likely to have continuous internal electronic fetal monitoring. This method provides data on the fetal heart rate. Depending upon the obstetric history, the client having back labor and the client with an uncomplicated labor may have intermittent fetal heart rate auscultation or external electronic fetal monitoring. The client who had a previous cesarean section would also have monitoring of uterine contraction intensity.)

A woman delivered her infant 24 hours ago by cesarean section. Which assessment findings should be reported to the assigned nurse? Select all that apply.

Uterus feels boggy The client reports breakthrough pain level of 7-8 (Following a cesarean section delivery, the client may experience numerous discomforts and problems. In this incidence, the fundal height is normal, the amount of bleeding is not abnormal, and mild abdominal distention with hypoactive bowel sound is expected. The concerning findings that need to be reported to the RN are the boggy uterus and the increased pain level. A boggy uterus can lead to hemorrhage and the pain level of 7-8 needs to be addressed with ordered narcotics.)

When assessing a postpartum woman, the nurse suspects the woman is experiencing a problem based on which finding?

acute decrease in hematocrit

The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which phase?

increment (Each contraction has three phases: increment or the buildup of the contraction; acme or the peak or highest intensity; and the decrement or relaxation of the uterine muscle fibers. The time from the onset to the highest intensity corresponds to the increment.)

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

improves pelvic floor tone

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

less than after a vaginal birth (Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.)

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?

oxytocin

An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply.

Has the mother ever been sensitized to Rh positive blood? Has the mother had any previous pregnancies? Has the mother experienced any miscarriages or abortions?

During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?

peribottle and warm water

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?

68 breaths per min (After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation.)

A nurse is providing care to a neonate and his mother. On reviewing the maternal history, the nurse notes that the mother's glucose level at birth was 102 mg/dL. The nurse would anticipate that the neonate's blood glucose level would be approximately:

71 to 82 mg/dL (Usually, a term newborn's blood glucose level is 70% to 80% of the maternal blood glucose level at birth. Using the mother's level of 102 and calculating 70% and then 80% of 102, the neonate's blood glucose would range between 71 to 82 mg/dL.)

The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location?

At the level of the umbilicus (After birth, the fundus is located midline between the umbilicus and symphysis pubis but then slowly rises to the level of the umbilicus during the first hour after birth. Then the uterus contracts approximately 1 cm (or fingerbreadth) each day after birth.)

A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural?

Administer a fluid bolus through the IV line to reduce the risk of hypotension (Epidurals can cause vasodilatation and result in hypotensive episodes. IV fluid bolus prior to epidural placement can help prevent the hypotensive episode.)

A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?

Administer pain medications.

Rho(D) immune globulin is administered to which clients? Select all that apply.

An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday An Rh-negative woman following an ectopic pregnancy A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?

Apply an ice pack to the site. (An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.)

A postpartum woman tells the home care nurse, "My hemorrhoids are really uncomfortable. Is there anything I can do?" Which suggestion(s) by the nurse would be appropriate? Select all that apply.

Applying ice to the area can help I will show you how to use a sitz bath Witch hazel pads can have a cooling effect

A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?

Ask the client to describe the intensity of her pain on a scale of 0 to 10.

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

Diuresis (Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in the first postpartum week does not cause major weight loss.)

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

Baseline FHR (The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.)

The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply.

Breasts are no painful Breasts feel slightly firm Flattened nipple on the right breast

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do *next*?

Check the fetal heart rate (When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.)

A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply.

Continue breastfeeding on left side, if the infant is willing to latch on Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse take in this situation?

Continue to monitor the fetal heart rate because this pattern is benign

The nurse is caring for a client who is a gravida 2 para 1 and had a previous cesarean section. The client has had no complications with the pregnancy and prefers to have this delivery vaginally. Which monitoring system best assesses for the ability to delivery vaginally?

Continuous internal monitoring of uterine contractions (Since this client has had a cesarean section, it is helpful to monitor uterine contractions, not resting tone. The nurse would follow the intensity of the contractions to avoid uterine rupture from the previous birth.)

The nurse has just administered morphine 2 mg IV to a laboring client. Which change in the fetal heart rate pattern would the nurse prioritize?

Decreased variability (Decreased variability (not increased) is a common side effect when opioid analgesics, such as morphine, are used. Early decelerations are gradual decreases in the FHR that mirror the contraction. Late decelerations indicate uteroplacental insufficiency and are not related to opioids.)

The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from:

Developing Rh sensitivity

The nurse is caring for a client experiencing pruritus secondary to opioid medication administration during labor. When reviewing the medication administration record, which medication would the nurse offer the client?

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

A new mother delivered 1 week ago and is tearful, anxious, sad, and has no appetite. She is diagnosed with postpartum blues. What factors contribute to this problem? Select all that apply.

Disrupted sleep patterns Fatigue Discomfort Hormonal changes

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?

Docusate (A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.)

Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? Select all that apply.

Fingernails are present and extend to the end of the fingers. Pinnae are flexible with rapid recoil. Creases on the feet cover 2/3 of the bottom of the feet.

A nurse is caring for a client in her third stage of labor. The nurse would predict the placenta is separating from the uterus based on which assessment findings? Select all that apply.

Fresh gushing of blood from the vagina Umbilical cord descending lower down A globular shaped uterus

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply.

Fundal height measurement Membrane status Contraction pattern

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel?

Fundus two fingerbreadths below umbilicus and firm

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation?

General (General anesthesia is reserved for emergencies in which the fetus must be delivered immediately to save the life of the fetus, mother or both. Regional anesthesia provides pain relief during labor and birth. Local anesthesia is typically a short-acting anesthesia used to numb the perineum.)

A nurse is preparing a presentation about 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.

Generalized swelling of the perineum Decreased bladder tone from regional anesthesia Use of oxytocin to augment labor

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do?

Have the client sit dangling her legs off the side of the bed for 5 minutes.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm.

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

Increased WBC count (The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor. During labor there could be a decrease, and not increase, in the blood coagulation time. There is an increased, not decreased, plasma fibrinogen level during labor. Blood glucose levels are decreased during labor.)

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication?

Increased lochia drainage (If the bladder is full in a postpartum mother, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. The other options do not happen if a woman has a distended bladder.)

Prior to discharge is an appropriate time to evaluate the client's status for preventative measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh negative mother?

Indirect coomb's test (The indirect Coombs' test is an antibody screen that will indicate whether or not the woman has been sensitized to the Rh positive blood of her infant. A positive result indicates the sensitization has occurred and this can cause complications for future pregnancies.)

The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply.

Inspect the episiotomy for sutures and to ensure that the edges are approximated Notes any hemorrhoids Gently palpate for any hematomas

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?

Intermittent fetal heart rate auscultation (The client is placed on an external fetal monitor for a 20-minute baseline and, if within normal limits, then is checked via a fetoscope or handheld Doppler at intermittent intervals. Continuous external monitoring may be initiated later in the labor process but is not identified from the history. Fetal scalp sampling gives evidence of the fetal status.)

A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.

Lightening Bloody show Backache (The signs of approaching labor include lightening, bloody show, and backache. Lightening is the falling forward of the pregnant uterus due to settlement of the fetal head into the maternal pelvis. Backache associated with pelvic cramping pain, which is regular and increases in intensity, is suggestive of impending labor. Bloody show is the expulsion of the cervical mucus plug tinged with blood, and occurs due to cervical effacement and dilation (dilatation). Weight loss and diarrhea are other signs of impending labor. Weight gain and constipation are not signs of impending labor.)

Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply.

Monitor maternal and fetal vital stats every hour Report an elevated temp over 38 C (100.4 F) Answer questions and encourage verbalization of fears (Consider what occurs in the latent (or early phase) of the first stage of labor, which are contractions and effacement. The nursing interventions that impact maternal and fetal injury include monitoring vital statistics, reporting temperature elevation over 38℃ (100.4℉), and answering questions and encouraging client verbalization of fears. The client is often excited and talkative. The client does not need to be on bed rest or positioned on the left side unless there is a complication.)

A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize?

Quickly evaluate the perineum.

A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply.

Respiratory distress Hypoglycemia Jaundice (Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.)

A nurse is conducting a class for a group of nurses who are newly hired for the labor and birth unit. After teaching the group about fetal heart rate patterns, the nurse determines the *need for additional teaching* when the group identifies which finding as indicating normal fetal acid-base status? Select all that apply.

Sinusoidal pattern Recurrent variable decelerations Fetal bradycardia (Predictors of normal fetal acid-base status include a baseline rate between 110 and 160 bpm, moderate baseline variability, and absences of later or variable decelerations. Sinusoidal pattern, recurrent variable decelerations, and fetal bradycardia are predictive of abnormal fetal acid-base status.)

The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction?

Temp 98.6 HR 74 RR 16 BP 150/85 (Postpartum women may have an elevated temp to 100.4° F (38° C) for 24 hours after birth; they may also have decreased pulse a few weeks after birth. The elevated BP of 150/85 is a concern, as a postpartum woman is still at risk of developing preeclampsia even after birth. The other choices are within normal limits.)

Which client should the postpartum nurse assess first after receiving shift report?

The 2 day postpartum client who has blood pressure 138/90 (The postpartum client with a blood pressure of 138/90 mm Hg is showing signs of hypertension and should be seen first to assess for preeclampsia. Preeclampsia can occur during the postpartum period. A pulse rate of 50 bpm and a respiratory rate of 20 breaths/minute are within the normal range. A fever of 100.4° F (38° C) or less during the first 24 hours postpartum is common.)

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area?

Through the anal sphincter muscle (A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.)

A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? Select all that apply.

Types of decelerations Variability (Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations like electronic fetal monitoring (EFM) can.)

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event?

Uteroplacental insufficiency (Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.)

Which interventions would the nurse take to reduce the incidence of infection in a postpartum woman? Select all that apply.

Wash her hands before and after caring for the client Encourage intake of fluids following delivery and after discharge Teach proper positioning of the infant for breastfeeding

The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?

instructing her to apply ice packs to both breasts every other hour

A nurse is assessing a term neonate and notes transient tachypnea. When reviewing the mother's history, which conditions would the nurse most likely find as contributing to this finding? Select all that apply.

cesarean birth use of heavy sedation during labor

What are common risk factors for developing newborn jaundice? Select all that apply.

fetal maternal blood group incompatibility prematurity breastfeeding certain drugs maternal gestational diabetes

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason?

improve pelvic floor tone

*A nursing instructor informs students that recent research has shown that delayed cord clamping provides which advantages? Select all that apply.*

improving the newborn's cardiopulmonary adaptation preventing childhood anemia increasing blood pressure improving oxygen transport increasing red blood cell flow

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths below the umbilicus