OB NCLEX Review questions CH 21, 22, 15

A primary care provider prescribes oral tocolytic therapy for a woman with preterm labor. The nurse explains to the client about the drugs that may be used. The nurse determines that the client needs additional teaching when she states which drug might be used for oral therapy? magnesium sulfate betamethasone indomethacin nifedipine

Correct Response:magnesium sulfate Rationale:Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone promotes fetal lung maturity by stimulating surfactant production.

A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential? unlimited visitation from family and friends fluid intake limitations use of clean gloves for invasive procedures meticulous handwashing

Correct Response:meticulous handwashing Rationale:Meticulous handwashing is essential for preventing postpartum infections, including before and after each client care activity. Aseptic technique, not clean gloves, are needed when performing invasive procedures. All visitors should be screened for any signs of active infection to reduce the risk for exposure. Adequate hydration, not fluid limitations, would be appropriate.

When assessing a postpartum woman, the nurse would find which factor to be most significant in identifying possible postpartum hemorrhage? blood pressure cardiac output hematocrit pulse rate

Correct Response:pulse rate Rationale:Tachycardia in the postpartum woman warrants further investigation. Typically, the postpartum woman is bradycardic for the first two weeks. In most instances of postpartum hemorrhage, blood pressure, and cardiac output remain increased because of a compensatory increase in heart rate. Red blood cell production ceases early in the puerperium, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

The nurse reviews the history of a postpartum woman, G3, P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client? uterine atony metritis postpartum hemorrhage deep venous thrombosis

Correct Response:deep venous thrombosis Rationale:Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34), and multiparity.

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." "You might think anesthetic sprays help but they do not." "Witch hazel pads can have a cooling effect." "I will show you how to use a sitz bath." "You should pour cold water over the area with your peribottle."

Correct Response:"Applying ice to the area can help.", "Witch hazel pads can have a cooling effect.", "I will show you how to use a sitz bath." Rationale:The presence of swollen hemorrhoids may heighten discomfort in the perineum. Local comfort measures such as ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths can relieve pain.

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. sleeping well feelings of worthlessness feeling overwhelmed restlessness hunger

Correct Response:feelings of worthlessness, feeling overwhelmed, restlessness Rationale:The symptoms of postpartum depression will last longer and are different than the baby blues. Some signs and symptoms of depression include feeling the following: restless, worthless, guilty, hopeless, moody, sad, and overwhelmed

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect? uterine atony uterine inversion laceration hematoma

Correct Response:laceration Rationale:Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

A nurse is preparing for a class to teach pregnant women and their partners about postpartum complications. Which measure would be most important for the nurse to emphasize as helping to prevent postpartum infection? adequate follow up with their health care provider handwashing limiting contact with outsiders for the first week ensure proper hydration

Your Response:handwashing Rationale:Stressing proper handwashing, especially after perineal care and before and after breast-feeding, will help to decrease the chances of infection and complications accompanying it. Although proper hydration and adhering to follow up are important, handwashing would be most important. Limiting contact with outsiders may or may not be preventative.

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

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

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? baby wipes alcohol wipes moist cloths peribottle and warm water

Your Response:peribottle and warm water Rationale:Local comfort measures for the perineum after an episiotomy or laceration include ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths.

After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition? lack of cervical dilation past 2 cm contractions most forceful in the middle of uterus rather than the fundus reports of severe back pain fetal buttocks as the presenting part

Your Response:reports of severe back pain Rationale:Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet. Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction.

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. hydramnios early ambulation breastfeeding uterine infection prolonged labor empty bladder

orrect Response:hydramnios, uterine infection, prolonged labor Rationale:Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? "You'll need to take this medication to stop the milk from being produced." "Try applying warm compresses to your breasts to encourage the milk to be released." "Limit the amount of fluid you drink so your breasts don't get much fuller." "Stop breastfeeding until the pain and swelling subside.

Correct Response:"Try applying warm compresses to your breasts to encourage the milk to be released." Rationale:Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breastfeeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present.

A nurse is providing care to a woman who is 6 hours postpartum. The nurse suspects urinary retention based on which finding? Urine clear yellow in color Fundus at the level of the umbilicus Moderate amount of lochia rubra 50 to 70 mL urine per void every hour

Correct Response:50 to 70 mL urine per void every hour Rationale:Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow and a need for catheterization. A uterus at the level of the umbilicus, moderate lochia rubra, and clear yellow urine are normal findings.

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which information would be important to collect first? STI status HIV status coagulation studies urinalysis results

Correct Response:coagulation studies Rationale:Coagulation studies should be obtained immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status and urinalysis results, although important, are not necessary emergently.

A nurse is making a follow up visit to a new parent and 3-month-old infant. The nurse is talking with the client about her role as a mother and caring for her infant. Which statement by the client would lead the nurse to immediately call the health care provider? "I feel really restless and sad, nothing seems to make me happy." "I get tearful every so often and then suddenly I am all smiles." "I am so angry with myself, I just want to give up my life right now." "It has been hard getting enough sleep with the infant waking up during the night."

Correct Response:"I am so angry with myself, I just want to give up my life right now." Rationale:The client's statement about being angry at herself and wanting to give up suggests postpartum psychosis. This information would need to be reported, because there is a threat to the mother's safety and possibly the infant's safety. The nurse should not leave the client alone. Postpartum psychosis generally surfaces within 3 months of giving birth and is manifested by sleep disturbances, fatigue, depression, and hypomania. The mother will be tearful, confused, and preoccupied with feelings of guilt and worthlessness. Early symptoms resemble those of depression, but they may escalate to delirium, hallucinations, extreme disorganization of thought, anger toward herself and her infant, bizarre behavior, delusions, disorientation, depersonalization, delirium-like appearance, manifestations of mania, and thoughts of hurting herself and the infant. The statement about not getting sleep may or may not be related to an affective disorder. It may be an indication of the mother attempting to adapt to the maternal role. The statement about getting tearful and then happy suggests emotional lability typically associated with postpartum blues; the statement about feeling restless and sad and lacking happiness suggest postpartal depression. Although these need to be reported and the nurse should continue to monitor the client, the statement about wanting to give up is of the utmost urgency.

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement? "My nipples won't be so dark after I give birth." "I might lose some hair, but it will grow back." "This line on my belly will go away over time." "I can't wait for these stretch marks to disappear after I give birth."

Correct Response:"I can't wait for these stretch marks to disappear after I give birth." Rationale:Stretch marks gradually fade to silvery lines but do not disappear completely. As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen, face, and nipples gradually fades.

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 5 months 2 months 4 months

Correct Response:3 months Rationale:Postpartum psychosis generally surfaces within 3 months of giving birth.

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? 8 to 10 weeks after pregnancy 6 to 8 weeks after pregnancy 2 to 4 weeks after pregnancy 4 to 6 weeks after pregnancy

Correct Response:6 to 8 weeks after pregnancy Rationale:During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their prepregnant state. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal.

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? Platelet level Prothrombin time Activated partial thromboplastin time Fibrinogen level

Correct Response:Activated partial thromboplastin time Rationale:The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? Fetus descends 2 cm per hour. Cervix dilates 2 cm per hour. Cervix dilates 1 cm per hour. Fetus descends 1 cm per hour.

Correct Response:Cervix dilates 1 cm per hour. Rationale:A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation. If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out.

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? Notify the birth attendant. Stop the infusion immediately. Continue to monitor contractions and fetal heart rate. Slow the oxytocin infusion to the initial rate.

Correct Response:Stop the infusion immediately. Rationale:The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: slightly increased. slightly decreased. acutely decreased. acutely increased

Correct Response:acutely decreased. Rationale:Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? amniotomy prostaglandin laminaria breast stimulation

Correct Response:amniotomy Rationale:Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

A nurse works at a facility that provides care to clients holding various cultural beliefs. The nurse integrates understanding of the areas recognized by other cultures that are not necessarily acknowledged by the Western culture. Which area would the nurse need to incorporate into the plans of care? allowing family members at the birth expectations of what the new mother should be doing balance of hot and cold introducing the infant to the rest of the family

Correct Response:balance of hot and cold Rationale:Two areas that are significantly different from Western culture involve beliefs about the balance of hot and cold and confinement after birth. Postpartum nurses need to understand these diverse cultural beliefs and provide creative strategies for encouraging hygiene, exercise, and balanced nutrition, while remaining respectful of the cultural significance of these practices.

As part of a review class for perinatal nurses, the nurse is explaining the laboratory and diagnostic tests that can be conducted to evaluate a woman's risk for preterm labor. The nurse determines that additional teaching is needed when the group identifies which test as being used? salivary estriol levels fetal fibronectin testing transvaginal ultrasound blood chemistry levels

Correct Response:blood chemistry levels Rationale:Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, amniotic fluid analysis, fetal fibronectin testing, cervical length evaluation by transvaginal ultrasound, salivary estriol, and home monitoring of uterine activity to recognize preterm contractions. Blood chemistry levels will inform the primary care provider as to the condition of the mother but would not be definitive in determining preterm labor risks.

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production? progesterone prolactin estrogen oxytocin

Correct Response:prolactin Rationale:Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? diaphoresis uterus 1 cm below umbilicus lochia serosa edematous vagina

Correct Response:uterus 1 cm below umbilicus Rationale:By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

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

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

A nurse is administering oxytocin to a woman in labor. The nurse monitors the infusion closely and notifies the health care provider if signs and symptoms of which condition occurs? Uterine hypotonicity Water intoxication Fetal distress Hypertension

Your Response:Water intoxication Rationale:Oxytocin can lead to water intoxication and can cause hypotension. Uterine hypertonicity is a possible adverse effect of oxytocin administration. Oxytocin does not cross the placental barrier, and no fetal problems have been observed.

A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem? White blood cell count 14,000/mm3 (14 ×109/L) Hemoglobin 12.5 g/dL (125 g/L) Platelets 350,000/μL (350 ×109/L) Hematocrit 42% (0.42)

Your Response:White blood cell count 14,000/mm3 (14 ×109/L) Rationale:The white blood cell count, which increases in labor, remains elevated for first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3 (6 to 10 ×109/L). An elevated white blood cell count would be suspicious for infection. The hemoglobin, hematocrit and platelet levels are within normal parameters for this woman

A 25-year-old nulliparous client presents in active labor. She has had no prenatal care, and her coagulation status is determined. Which result would the nurse identify as placing the client at risk for postpartum hemorrhage? international normalized ratio (INF) 1.0 activated partial thromboplastin time 60 seconds platelet 350,000 prothrombin time 11 seconds

Your Response:activated partial thromboplastin time 60 seconds Rationale:Activated partial thromboplastin time of 60 seconds is increased and suggestive of a coagulopathy. The platelet count, prothrombin time, and INR are within normal parameters.

A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client? encouraging the woman to assume a hands-and-knees position preparing the woman for an amniotomy providing a comfortable environment with dim lighting administering oxytocin

Your Response:administering oxytocin Rationale:Oxytocin would be appropriate for the woman experiencing dysfunctional labor (hypotonic uterine dysfunction). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used if the membranes were intact. It may also be used with hypotonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus? cervical lacerations infection of episiotomy caput succedaneum perineal hematoma

Your Response:caput succedaneum Rationale:Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps-assisted birth. Maternal complications include tissue trauma such as lacerations of the cervix, vagina, and perineum; hematoma; extension of episiotomy into the anus; hemorrhage; and infection.

A client at 32 weeks' gestation has been admitted to the labor and birth unit with preterm labor. Which medication would the nurse be likely to administer to reduce the risk of complications in the preterm newborn? indomethacin corticosteroids nifedipine magnesium sulfate

Your Response:corticosteroids Rationale:Corticosteroids are given to help reduce or prevent the frequency and severity of respiratory distress syndrome in preterm infants delivered between 24 and 34 weeks' gestation. Medications most commonly used for tocolysis include magnesium sulfate, indomethacin, and nifedipine.

A nurse is reading a journal article about cervical ripening agents, based on the understanding that certain pharmaceuticals can be used to attain cervical ripening in women who need assistance in this area. They have also often continued into labor without further agents to stimulate uterine contractions. Which agent would the nurse anticipate reading about as an FDA-approved agent for cervical ripening? oxytocin misoprostol magnesium sulfate dinoprostone

Your Response:dinoprostone Rationale:Dinoprostone is approved by the FDA as the only cervical ripening agent to be used; however, ACOC acknowledges the apparent safety and effectiveness of misoprostol for this purpose as well. It is contraindicated in women with prior uterine scars. It is also known to cause hyperstimulation of the uterus, which can lead to other complications. Magnesium sulfate is used in hygroscopic dilators to assist in a mechanical method of cervical dilation.

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding? extreme periods of elation lack of pleasure feels like eating all the time over interest in her baby

Your Response:lack of pleasure Rationale:Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed, cry a lot, exhibit a lack of energy and motivation, experience a lack of pleasure, changes in appetite, sleep, or weight, withdraw from friends and family, feel negatively toward her baby, or shows lack of interest in her baby.

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

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

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring? precipitate labor dystocia normal labor preterm labor

Your Response:preterm labor Rationale:Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from start of contraction to birth.

A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate? preparing the woman for an amniotomy administering oxytocin encouraging the women to change positions frequently providing a comfortable environment with dim lighting

Your Response:providing a comfortable environment with dim lighting Rationale:Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. This action is consistent with assisting a women experiencing problems with the psyche. Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). An amniotomy may be used with hypertonic uterine dysfunction to augment labor. Frequent position changes would be appropriate for a woman with persistent occiput posterior position (problem with the passenger).

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which medication if prescribed would the nurse question? carboprost misoprostol methylergonovine oxytocin

arboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, misoprostol should not be given to women with active CVD, pulmonary or hepatic disease, and methylergonovine should not be given to a woman who is hypertensive.

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? "I didn't realize all that went into being a dad. I wasn't prepared for this." "I've learned how to diaper and bathe the baby so I can be a really involved dad." "It'll be fun to have a baby in the house, but things shouldn't change too much." "I may not be a pro at helping out with the baby, but I enjoy being involved."

Correct Response:"I didn't realize all that went into being a dad. I wasn't prepared for this." Rationale:The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery. Clear ResponseHide Answer Submit Qui

After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment? "I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months." "We're going to use a barrier for the first few months and then decide what we want to do." "We will be discussing birth control with our primary care provider to find the best method for us." "I'm going back on the pill as soon as the doctor okays it."

Correct Response:"I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months." Rationale:Breastfeeding is not a totally reliable method of contraception unless the mother exclusively breastfeeds, has had no menstrual period since giving birth, and whose infant is younger than 6 months old; however, ovulation may occur before menstruation.

During a home visit with new parents, the nurse also assesses the new father's adaptation to his new role. Which statement would indicate that he is in the expectation stage? "It'll be fun to have a baby in the house, but things shouldn't change too much." "I didn't realize all that went into being a dad. I wasn't prepared for this." "I may not be a pro at helping out with the baby, but I enjoy being involved." "I've learned how to diaper and bathe the baby so I can be a really involved dad."

Correct Response:"It'll be fun to have a baby in the house, but things shouldn't change too much." Rationale:The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.

A pregnant client's labor has been progressing slower than normal. The client is visibly anxious and tense, telling the nurse, "I am so worried about what is going to happen. And I am so tired and feel so helpless." Other underlying issues that may be contributing to the client's slow labor progress have been ruled out. Which response(s) by the nurse would be appropriate? Select all that apply. "Let me leave you alone for a little while so you can get some rest." "Maybe dimming the lights or some soft music will help you relax a bit." "I will keep you updated often on how you and your baby are doing." "I will have to stop giving you pain medicine because it is slowing your labor." "Things are moving along but sometimes it can take a little longer."

Correct Response:"Maybe dimming the lights or some soft music will help you relax a bit.", "I will keep you updated often on how you and your baby are doing.", "Things are moving along but sometimes it can take a little longer."

A pregnant client's labor has been progressing slower than normal. The client is visibly anxious and tense, telling the nurse, "I am so worried about what is going to happen. And I am so tired and feel so helpless." Other underlying issues that may be contributing to the client's slow labor progress have been ruled out. Which response(s) by the nurse would be appropriate? Select all that apply. "Maybe dimming the lights or some soft music will help you relax a bit." "Things are moving along but sometimes it can take a little longer." "I will keep you updated often on how you and your baby are doing." "Let me leave you alone for a little while so you can get some rest." "I will have to stop giving you pain medicine because it is slowing your labor."

Correct Response:"Maybe dimming the lights or some soft music will help you relax a bit.", "Things are moving along but sometimes it can take a little longer.", "I will keep you updated often on how you and your baby are doing." Rationale:The client is experiencing problems with the psyche. The nurse should provide emotional support to the client and family. Comfort measures such as dimming the lights or putting on soft music can promote relaxation and help the client's body work more effectively with the forces of labor. Keeping the client updated about her status and that of her fetus can provide reassurance and encouragement. Explanations about labor and what to expect can help empower the client and help her cope. The nurse should provide continuous presence to allay anxiety. Pain medication is needed to reduce anxiety and stress.

The client is anxious about her prolonged pregnancy. She informs the nurse she has been doing research on the Internet and has read about certain herbs that can help to induce labor. Which response from the nurse would be appropriate? "Why would you do something as stupid as that?" "Please talk to your primary care provider first to ensure it is safe." "Personally, I would use them, but I cannot tell you to." "There is no scientific evidence they work. You will just complicate your situation more."

Correct Response:"Please talk to your primary care provider first to ensure it is safe." Rationale:It is important that the primary care provider knows if and when the client is using herbal supplements to ensure there will be no danger to the woman or fetus. The risks and benefits of these agents are unknown. None have been evaluated scientifically, and thus none can be recommended regarding their efficacy or safety. The statement about personal use is inappropriate because the nurse should not reveal personal information. Telling the client that the herbs will complicate the situation is inappropriate because the statement is judgmental and there is no information, whether positive or negative that the herbs can be harmful. The statement about doing something stupid is demeaning to the client.

After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? "Postpartum depression develops gradually, appearing within the first 6 weeks." "Postpartum blues usually resolves by the 4th or 5th postpartum day." "Postpartum psychosis usually involves psychotropic drugs but not hospitalization." "Postpartum psychosis usually appears soon after the woman comes home."

Correct Response:"Postpartum depression develops gradually, appearing within the first 6 weeks." Rationale:Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

A new mother comes in for her first visit and reports pain and tenderness in her breast just before feeding. Based on her description, the nurse determines she is experiencing breast engorgement. Which instruction should the nurse provide to her? "Use ice for about 15 minutes every other hour to promote comfort." "Take a warm shower just before feeding your infant." "Try not to touch your breasts or nipples until the swelling subsides." "Wear a supportive tight bra all day long."

Correct Response:"Take a warm shower just before feeding your infant." Rationale:Standing in a warm shower or applying warm compresses immediately before feedings will help soften the breasts and nipples to allow the newborn to latch on more easily and will enhance the let-down reflex. Wearing a tight supportive bra all day is appropriate for the woman who is not breastfeeding. Frequent emptying of the breasts helps to resolve engorgement, so the mother should be encouraged to feed the newborn, which would involve touching her breasts and nipples. The breastfeeding woman should apply cold compresses, but not ice, to her breasts between feedings to reduce swelling.

During a postpartum home visit, a woman tells the nurse that her hip joints are sore, just like they were when she was pregnant. Which information would the nurse likely include when teaching the woman about this condition? Select all that apply. "It is important to lie down on your back at least 3 times a day." "This soreness should go away in about 6 to 8 weeks." "Let me show you how to use good body mechanics to lessen the problem." "It is important to get this checked out with an x-ray just to make sure." "You will probably need to take an opioid pain medicine for a few weeks."

Correct Response:"This soreness should go away in about 6 to 8 weeks.", "Let me show you how to use good body mechanics to lessen the problem." Rationale:During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their prepregnant state, with the exception of the woman's feet. Women commonly experience fatigue and activity intolerance and have a distorted body image for weeks after birth secondary to declining relaxin and progesterone levels, which cause hip and joint pain that interferes with ambulation and exercise. Good body mechanics and correct positioning are important during this time to prevent low back pain and injury to the joints. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal. Joint soreness is not a cause for concern. Opioids or x-rays are not needed. It is important for the woman to be active and exercise, so lying in bed 3 times a day would not be helpful.

A nurse is providing care to a postpartum woman who is breastfeeding her 1-day old neonate. While observing the interaction, the woman says to the nurse, "I have noticed some tingling in both of my breasts just before my baby starts to feed and then for a bit during the feeding. What is happening?" Which response by the nurse would be appropriate? "I need to call your provider because it sounds like you might be developing an infection." "Tingling in your breasts is most likely a sign that your breast tissue is swollen." "There must be something causing a blockage in your milk ducts." "What you are feeling is the normal let-down reflex when milk is released."

Correct Response:"What you are feeling is the normal let-down reflex when milk is released." Rationale:Typically, during the first 2 days after birth, the breasts are soft and nontender. The woman may also report a tingling sensation in both breasts, which is the "let-down reflex" that occurs immediately before or during breastfeeding. This tingling is not a sign of infection or blockage of the milk ducts. Engorgement is a postnatal physiologic painful condition in which distension and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation. Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the following 24 to 36 hours.

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate? "Try doing Kegel exercises to get your pelvic muscles back in shape." "You might try using a water-soluble lubricant to ease the discomfort." "It takes a while to get your body back to its normal function after having a baby." "This is entirely normal, and many women go through it. It just takes time."

Correct Response:"You might try using a water-soluble lubricant to ease the discomfort." Rationale:Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A postpartum woman is being treated for hemorrhage and is to receive a blood transfusion. The nurse understands that this treatment is being instituted based on which amount of estimated blood loss? 1,500 mL 750 mL 1000 mL 1,250 mL

Correct Response:1,500 mL Rationale:Once estimates of blood loss reach 1,500 mL to 2000 mL, transfusion of blood products should be instituted immediately.

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 750 mL 1000 mL 500 mL 300 mL

Correct Response:1000 mL Rationale:Postpartum hemorrhage is defined as a cumulative blood loss greater than 1,000 mL with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery

A nurse is developing a plan of care for a postpartum woman, newborn, and partner to facilitate the attachment process. Which intervention would be appropriate for the nurse to include in the plan? Urge parents to talk to each other when holding the baby. Encourage contact between the newborn's skin and parental clothing. Ensure early and frequent parent-newborn interactions. Have the parents participate in newborn care once a day

Correct Response:Ensure early and frequent parent-newborn interactions. Rationale:Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and their partners to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breastfeeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care. Eye contact and interacting with the newborn during feeding helps to promote attachment and bonding.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal? Escherichia coli Staphylococcus aureus Gardnerella vaginalis Klebsiella pneumoniae

Correct Response:Escherichia coli Rationale:E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections.

A pregnant client is experiencing dystocia resulting from persistent occiput posterior position. The client, in the first stage of labor, is reporting significant back pain. The nurse encourages the client to change positions frequently for comfort and to help promote rotation of the fetal head. Which position(s) would be appropriate for the nurse to suggest? Select all that apply. Trendelenburg Hands and knees Squatting Side-lying Modified Sims

Correct Response:Hands and knees, Squatting, Side-lying Rationale:Appropriate maternal position changes to promote fetal head rotation include hands and knees, rocking pelvis back and forth, side-lying position, side lunges during contractions, sitting, kneeling, or standing while leaning forward, and the squatting position (to give birth and enlarge the pelvic outlet). Modified Sims and Trendelenburg are appropriate for umbilical cord prolapse.

A nurse is teaching a 42-week nulliparous pregnant woman about labor induction which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction? amniotic fluid studies Bishop scoring Maneuvers for fetal positioning fetal dating

Correct Response:Maneuvers for fetal positioning Rationale:Before labor induction is started, fetal maturity (dating, ultrasound, amniotic fluid studies) and cervical readiness (vaginal examination, Bishop scoring) must be assessed. Both need to be favorable for a successful induction. Maneuver's to determine fetal position (Leopold's maneuver) is a technique done as the fetus moves through the labor process.

A nurse is making a postpartum home visit to a woman who gave birth vaginally about 12 days ago. The woman's partner is present during the visit. When assessing the woman and the family, which finding related to the partner would lead the nurse to suspect that the partner may be experiencing postpartum depression? Select all that apply. Reports of feeling highly stressed Feelings of being unprepared for the role Use of encouraging statements about the infant Reports of frequent headaches Statements that woman is getting all the attention

Correct Response:Reports of feeling highly stressed, Reports of frequent headaches, Statements that woman is getting all the attention Rationale:A partner's stress, irritability and frustration in the days, weeks, and months after the birth of the child can turn into depression, just like that experienced by the mother. Unfortunately, partners rarely discuss their feelings or ask for help, especially during a time when they are supposed to be the "strong one" for the new mother. Symptoms of depression appear 1 to 3 weeks after birth and can include feelings of high stress, anxiety, discouragement, fatigue, headaches, and resentment toward the infant and the attention he or she is getting. Partners experiencing these symptoms should understand that it is not a sign of weakness, and professional help can be helpful. Partner statements about not being prepared for the role is a common feeling and part of the role development process indicating reality.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? Showing increased confidence when caring for the newborn Having feelings of grief or guilt Pointing out specific features in the newborn Talking about her labor experience to others around her

Correct Response:Showing increased confidence when caring for the newborn Rationale:Independence with self-care is an important aspect of the taking-hold phase. During the letting-go phase, the woman assumes responsibility and care for the newborn with increased confidence. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

A G3, P2 woman arrives at the birthing center stating that she has been in labor for the past 18 hours. The nurse suspects a protracted labor pattern disorder based on which finding? Poor contraction quality and intensity Incomplete relaxation of the uterus between contractions Slower than usual cervical dilation Fetal face presentatio

Correct Response:Slower than usual cervical dilation Rationale:The term protracted disorders refer to a series of events including protracted active phase dilation (slower-than-normal rate of cervical dilation) and protracted descent (delayed descent of the fetal head in the active phase). A laboring woman with a slower-than-normal rate of cervical dilation is said to have a protracted labor pattern disorder. Poor contraction quality and intensity is associated with hypotonic uterine dysfunction. Incomplete uterine relaxation between contractions is associated with hypertonic uterine dysfunction. Fetal face presentation is a problem with the passenger affecting labor progress.

A nurse is describing the many changes that will occur during the early postpartum period with a group of young parents. The nurse reviews common reports experienced as the woman's body returns to her prepregnancy state. The nurse determines that the teaching was successful when the participants identify which report as being most common during the first week that will indicate their fluid volume is returning to normal? diaphoresis nocturia urinary urgency urinary frequency

Correct Response:diaphoresis Rationale:The profuse diaphoresis is common during the early postpartum period. Many women will wake up drenched with perspiration. This diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. It is common, especially at night during the first week after birth. Nocturia, urinary frequency, or urinary urgency are not associated with this fluid shift.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? preexisting conditions in the client medications used during labor and birth drop in estrogen and progesterone levels after birth lack of social support from family or friends

Correct Response:drop in estrogen and progesterone levels after birth Rationale:Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply. early ambulation uterine infection breastfeeding hydramnios prolonged labor

Correct Response:early ambulation, breastfeeding Rationale:Factors that inhibit involution that would result in subinvolution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution

When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement? human chorionic gonadotropin (hCG) prolactin estrogen progesterone

Correct Response:estrogen Rationale:Decreased levels of estrogen are associated with breast engorgement and with the diuresis that occurs postpartum. Progesterone and hCG are not involved with breast engorgement. Prolactin levels remain elevated in the lactating woman for milk synthesis and secretion, but decrease within 2 weeks for the woman who is not breast-feeding.

The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone? progesterone estrogen prolactin hCG

Correct Response:estrogen Rationale:The endocrine system rapidly undergoes several changes after birth. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. hCG and prolactin are not associated with postpartum diuresis.

The mental health clinical nurse specialist is teaching a postpartum nurse how to use the Postpartum Depression Predictor Scale (PDSS) to assess for postpartum depression. The nurse specialist determines the need for additional teaching when the nurse identifies which component as being screened with the scale? family and social support system guilt emotional lability cognitive impairment

Correct Response:family and social support system Rationale:The PDSS is a self-report, 35-item Likert-type response scale divided into seven conceptual domains: anxiety/insecurity; sleep/eating disturbance; emotional lability; loss of self-esteem; guilt/shame; cognitive impairment; and suicidal thoughts.

A young mother is at the office for her 6-week visit. She is still experiencing mild loch alba and is concerned that she has an infection. Which finding would the nurse interpret as supporting this suspicion? creamy discharge foul odor light brown discharge fleshy smell

Correct Response:foul odor Rationale:At 3 to 6 weeks, the lochia alba is in the final stage. The discharge is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content. Lochia at any stage should have a fleshy smell; an offensive odor usually indicates an infection.

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor? retained placental fragments loss of protection with premature rupture of membranes prolonged labor with multiple vaginal examinations to evaluate progress increased vaginal acidity leading to growth of bacteria

Correct Response:increased vaginal acidity leading to growth of bacteria Rationale:Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth

A woman presents to her first postpartum visit reporting she does not feel well. Which findings would lead the nurse to suspect that she has developed endometritis? Select all that apply. leukocytosis flank pain pain on both sides of the abdomen odorless lochia hematuria

Correct Response:leukocytosis, pain on both sides of the abdomen Rationale:Signs and symptoms of endometritis include lower abdominal tenderness or pain on one or both sides, foul-smelling lochia, and leukocytosis. Hematuria and flank pain would be associated with a urinary tract infection.

The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest? playing a recording of their voices at all times keeping the baby in the same room at all times promoting skin-to-skin contact on the chest sleeping with the infant

Correct Response:promoting skin-to-skin contact on the chest Rationale:Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and fathers to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breast-feeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care.

A 19-year-old nulliparous is in early labor with erratic contractions. An assessment notes that she is remaining at 3 cm. There is also a concern that the uterus is not fully relaxing between contractions. The nurse suspects which complication? reduced oxygen to the fetus ruptured uterus precipitate labor cephalopelvic disproportion

Correct Response:reduced oxygen to the fetus Rationale:Hypertonic uterine dysfunction occurs when the uterus never fully relaxes between contractions. Placental perfusion becomes compromised, thereby reducing oxygen to the fetus. This occurs in early labor and affects nulliparous women more than multiparous women. A ruptured uterus is a potential complication; however, hypoxia to the fetus would occur first. Cephalopelvic disproportion is usually associated with hypotonic uterine dysfunction. Precipitate labor is one that is completed in less than 3 hours from the start of contractions to birth.

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which primary conditions? Select all that apply. severe preeclampsia ectopic pregnancy abruptio placenta isoimmunization septicemia

Correct Response:severe preeclampsia, abruptio placenta, septicemia Rationale:DIC is not itself a specific illness; rather it is always a secondary diagnosis that occurs as a complication of placental abruption, anaphylactoid syndrome of pregnancy, intrauterine fetal death with prolonged retention of the fetus, acute fatty liver of pregnancy, severe preeclampsia, HELLP syndrome (hemolysis, i.e., the breakdown of red blood cells, elevated liver enzymes, and low platelet count), septicemia, and postpartum hemorrhage.

Every postpartum client has the potential of hemorrhage. While assessing a client's status, which finding would be of little benefit in identifying the possibility of hemorrhage? signs of shock uterine tone vital signs estimated amount of blood loss

Correct Response:signs of shock Rationale:Signs of shock do not appear until the hemorrhage is far advanced due to the increased fluid and blood volume of pregnancy. Vital signs would show an increased pulse rate and decreased level of consciousness. The amount of lochia would be much greater than usual, and urinary output would be diminished with signs of acute renal failure. The uterus may also appear soft and spongy instead of firm.

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? letting-go phase taking-hold phase attachment phase taking-in phase

Correct Response:taking-in phase Rationale:During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

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 39° C or higher after the first 48 hours after birth temperature of 37.5° C or higher after the first 12 hours after birth temperature of 38.5° C or higher after the first 36 hours after birth temperature of 38° C or higher after the first 24 hours after birth

Correct Response:temperature of 38° C or higher after the first 24 hours after birth Rationale:Postpartum infection is defined as a fever of 38° C or 100.4° F or higher after the first 24 hours after birth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours.

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5 Ts tool will recognize which as a potential causes of postpartum hemorrhage? Select all that apply. time thrombin tone tissue technique of birth

Correct Response:thrombin, tone, tissue Rationale:A helpful way to remember the causes of postpartum hemorrhage is by using the 5 Ts: tone, tissue, trauma, thrombin, and traction.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine prolapse uterine contraction uterine atony uterine subinvolution

Correct Response:uterine atony Rationale:Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.

During an assessment, the nurse notes that the client has been unable to urinate properly since giving birth and is bleeding more than expected. The nurse suspects which condition? postpartum diaphoresis urinary tract infection pain when voiding uterine atony

Correct Response:uterine atony Rationale:The client exhibits the signs of uterine atony, urinary retention and excessive bleeding. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. The client will have increased diaphoresis as the body works to decrease the blood volume that was necessary during the pregnancy. Although the client may have a urinary tract infection, there is no finding to support this as a cause, such as painful urination and frequent voiding.

After teaching a class of pregnant women on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states: "I should drink more so I don't get dehydrated." "At least I don't have to give up smoking for this one." "He has to do the deep breathing exercises with me." "Using passive range-of-motion exercises in bed sounds easy enough."

Your Response:"At least I don't have to give up smoking for this one." Rationale:Preventing thrombotic conditions is an important aspect of postpartum care and proper nursing management. There are many simple measures that can be utilized, to include encouraging leg exercises and walking; using intermittent sequential compression devices; stopping smoking to reduce or prevent vascular vasoconstriction; using compression stockings; performing passive range-of-motion exercises while in bed; using postoperative deep breathing exercises to improve venous return; and increasing fluid intake to prevent dehydration

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? "If my lochia increases, I need to call my health care provider." "If I get a cut, I need to apply direct pressure for about 5 minutes or more." "I need to avoid using any aspirin-containing products." "I should brush my teeth vigorously to stimulate the gums."

Your Response:"I should brush my teeth vigorously to stimulate the gums." Rationale:The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.

A pregnant client in labor experiences a problem with the passenger related to shoulder dystocia. The health care provider is planning to relieve it with McRobert maneuver. The client asks the nurse, "What is going to happen when they try this?" Which response by the nurse would be appropriate? "You will get a medicine to increase the strength and frequency of your contractions to move things along." "A gel will be placed in your vagina to soften the cervix and allow the baby to move." "Your thighs will be flexed and moved away from the center of your body to open things up." "The provider will place firm pressure on the area just above your pubic bone to unstick the shoulder."

Your Response:"Your thighs will be flexed and moved away from the center of your body to open things up." Rationale:Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. Shoulder dystocia is a fundamentally mechanical problem. The McRoberts maneuver can reduce the severity of injuries to the mother and newborn. With the McRobert maneuver, the mother's thighs are flexed and abducted as much as possible to straighten the pelvic curve. With suprapubic pressure, light pressure is applied just above the pubic bone, pushing the fetal anterior shoulder downward to displace it from above the mother's symphysis pubis. The newborn's head is depressed toward the mother's anus while light suprapubic pressure is applied. Cervical ripening or medicine to stimulate uterine contractions would not be appropriate with shoulder dystocia.

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

Your Response:4,000 g to 4500 g Rationale:Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.13 to 9.15 lb) or more at birth, complicates approximately 10% of all pregnancies The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: 7 6 5 9

Your Response:5 Rationale:A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

The nurse is assisting a young mother who has decided not to breastfeed her infant. The nurse should make which suggestions to the client to ease discomfort and prevent breast engorgement? Select all that apply. Pump her breasts once a day only. Take a hot shower. Apply ice to the breast for approximately 15 to 20 minutes every other hour. Avoid sexual stimulation. Wear tight supportive bra 24 hours each day.

Your Response:Apply ice to the breast for approximately 15 to 20 minutes every other hour., Avoid sexual stimulation., Wear tight supportive bra 24 hours each day. Rationale:For women who are not breastfeeding, some current relief measures include wearing a tight, supportive bra 24 hours daily; applying ice to her breasts for approximately 15 to 20 minutes every other hour; avoiding sexual stimulation; and not stimulating the breasts by squeezing or manually expressing milk from the nipples. In addition, avoiding exposing the breasts to warmth will help relieve breast engorgement.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time? Assist the family in making arrangements for their stillborn infant. Give the parents a lock of the infant's hair. Allow the couple to spend as much time as they want with their stillborn infant. Avoid any discussion of the situation with the couple.

Your Response:Avoid any discussion of the situation with the couple. Rationale:The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action? Keeping the communication lines open. Contacting a grief counselor. Leaving the parents alone. Removing the infant quickly.

Your Response:Keeping the communication lines open. Rationale:Failing to keep the lines of communication open with a bereaved client and her family closes off some of the channels to recovery and healing. Staff members that avoid dealing with the situation may imply that the problem will go away. As a result the family's needs go unrecognized, and they may feel isolated. The parents should be allowed to spend as much time as they need with the infant as it will help make the situation more real, help them in the grieving process, and allow them to say goodbye.