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What clinical manifestation requires immediate intervention in a woman with a probable ruptured tubal pregnancy?
1 Abdominal distention 2 Intermittent abdominal contractions 3 Dull, continuous upper-quadrant abdominal pain Correct4 Sudden onset of knifelike pain in one of the lower quadrants One symptom of sudden rupture of a fallopian tube is pain on the affected side, usually sudden, excruciating, and radiating over the lower abdomen and to the shoulder; sometimes the pain is associated with nausea, vomiting, and diarrhea. Abdominal distention is not a classic sign of a ruptured fallopian tube. There are no contractions because the pregnancy is not uterine. The pain is exquisite, sharp (not dull) and sudden in the lower abdomen when the fallopian tube ruptures.
A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/dL. What is the next nursing action?
1 Checking with the nurse manager to see whether the client may go home 2 Reassessing the client for signs of infection by taking her vital signs 3 Delaying the client's discharge until the practitioner has conducted a complete examination Correct4 Placing the report in the client's record because this is an expected postpartum finding Leukocytosis (15,000-20,000 mm3 WBC) typically occurs during the postpartum period as a compensatory defense mechanism. There is no need for further intervention, because the client is exhibiting an expected postpartum leukocytosis.
A client at 7 weeks' gestation tells a nurse in the prenatal clinic that she is sick every morning with nausea and vomiting and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of the:
1 Fifth month Correct2 Third month 3 Fourth month 4 Second month Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin.
Which finding indicates the development of a complication resulting from the presence of bilateral cephalhematomas?
1 Urine output Correct2 Skin color 3 Glucose level 4 Rooting/sucking reflex Cephalhematomas are gradually absorbed. As the hematoma resolves, hemolysis of red blood cells occurs, and jaundice may result. Glucose level, urine output, and the rooting/sucking reflex are not affected by a cephalhematoma.
A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. Folic acid is important for this client because it: 1 Lessens sickling of RBCs 2 Prevents vaso-occlusive crises 3 Decreases cellular oxygen need Correct4 Compensates for a rapid turnover of red blood cells
Folic acid is needed to produce heme for hemoglobin. Supplementation with folic acid does not reduce sickling, and it will not prevent vaso-occlusive crisis. Adequate oxygenation and hydration help prevent vaso-occlusive crisis (painful episode). There is no change in needs; sickling decreases the oxygen-carrying capacity of hemoglobin.
An almost term client reports that her fetus is moving less this week than last week. Which responses are appropriate? (Select all that apply.) 1 Don't worry — the fetus sleeps a lot near the end of the pregnancy." Correct2 "It would be good for you to come to labor and delivery to be evaluated today." Correct3 "Always call the health care provider if you're worried that your baby isn't moving enough." Correct4 "Let me teach you how to conduct a kick count, and then you can call me when you've done one."
If a client is reporting decreased fetal movement, it is appropriate to advise her to contact her health care provider, be evaluated, and conduct a kick count. Infant movement is a sign of infant well-being, and a reported decrease should not be ignored. The mother should also always be encouraged to call her health care provider, at any time, if she has concerns about her pregnancy and the well-being of her baby.
A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement?
1 "Breastfeed four times a day, then offer water if the baby cries." 2 "Offer just one bottle a day when you're experiencing discomfort." Correct3 "Nurse at least every 3 hours for at least 10 minutes on each breast." 4 "Limit nursing to 4 to 6 minutes on each breast at least six times a day." Frequent nursing reduces engorgement. A 10-minute session permits complete emptying of the breast. Offering water will not decrease engorgement; in addition, the infant will be deprived of nourishment. A relief bottle will prevent emptying of the breasts; it will increase pain and swelling. Limiting nursing does not permit complete emptying of the breasts.
A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored?
1 Sinus tachycardia 2 Urinary frequency 3 Respiratory distress Correct4 Hypotensive episodes Epidural anesthesia creates a sympathetic block that causes loss of peripheral vascular resistance and a decrease in venous return; this leads to a reduced cardiac output, which can precipitate hypotensive episodes. Bradycardia, not tachycardia, may result. The urge to void is diminished with epidural anesthesia; the client should be encouraged to void to prevent distention. Respiratory distress is not a common side effect of epidural anesthesia; it may occur if an accidental high placement of anesthetic occurs or an excessive amount of anesthesia is administered.
What nursing action is the priority for a client in the second stage of labor?
Incorrect1 Check the fetus's position 2 Administer medication for pain Correct3 Promote effective pushing by the client 4 Explain that breastfeeding can start right after birth Effective pushing will hasten the passage of the fetus's presenting part through the birth canal. The fetal position is established before the second stage. Birth is imminent, and medication given at this time will depress the newborn's respirations. Although the mother may breastfeed after the birth, during the second stage of labor she should be concentrating on the birth process, not feeding the infant
The nurse visualizes and palpates a generalized, soft, edematous area of the scalp on the occiput of a newborn. What does the nurse suspect?
Incorrect1 Hydrocephalus 2 Cephalhematoma 3 Subdural hematoma Correct4 Caput succedaneum Pressure against the fetal head during labor can cause localized trauma, which results in edema that is not confined within the suture lines of the skull. The edematous area is usually generalized and on the occiput. Hydrocephalus occurs when the ventricles in the brain fill with cerebrospinal fluid as a result of a congenital malformation such as stenosis of the aqueduct of Sylvius. In the newborn it manifests as an enlarged head with a bulging anterior fontanel; the head circumference is more than 1½ inches (4 cm) larger than the chest circumference. Pressure against the fetal head during labor can cause a collection of blood beneath the periosteum from ruptured blood vessels; this does not cross the suture line and is not generalized. Subdural hematoma is not palpable; the neonate will demonstrate signs of increased intracranial pressure.
What signs and symptoms of withdrawal does the nurse identify in a postpartum client with a history of opioid abuse? Incorrect
Incorrect1 Paranoia and evasiveness 2 Extreme hunger and thirst 3 Depression and tearfulness Correct4 Irritability and muscle tremors The earliest sign of opioid withdrawal is central nervous system overstimulation. Paranoia and evasiveness are related to opioid drug abuse, not opioid withdrawal. Extreme hunger and thirst have no relation to opioid withdrawal; most postpartum women are hungry and thirsty. Depression and tearfulness are not specific to people who abuse opioids.
During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?
1 Report this finding 2 Administer nasal oxygen 3 Lower the head of the bassinette Correct4 Remove secretions from the pharynx An increase in mucus production is expected during the second reactive period; mucus should be removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device. Reporting this finding is unnecessary; identifying and treating human responses is within the scope of nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages. Although lowering the head of the bassinet may help secretions drain, the newborn cannot remove secretions that block respirations.
What is the best nursing intervention to minimize perineal edema after an episiotomy?
Correct1 Applying ice packs 2 Offering warm sitz baths 3 Administering aspirin prn 4 Elevating the hips on a pillow Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides little or minimal perineal relief.
During a prenatal visit a client who is at 36 weeks' gestation states that she is having uncomfortable irregular contractions. How should the nurse respond?
1 "Lie down until they stop." Correct2 "Walk around until they subside." Incorrect3 "Time the contractions for 30 minutes." 4 "Take 2 extra-strength aspirin if the discomfort persists." Ambulation relieves the discomfort of preparatory (Braxton Hicks) contractions. These contractions will increase when the client is resting. Preparatory contractions are not indicative of true labor and need not be timed. Aspirin may be harmful to the fetus because it can hemolyze red blood cells.
On her first prenatal visit a client says to the nurse, "I guess I'll be having an internal examination today." What is the nurse's best response?
1 "Yes, an internal exam is done at the mother's first visit." 2 "Are you worried about having an internal examination?" Correct3 "Have you ever had an internal examination done before?" 4 "Yes, a slightly uncomfortable internal exam must be done." Before health teaching is instituted, the nurse should ascertain the client's past experiences; they will influence the teaching plan. Stating that an internal exam is performed on the mother's first visit does not give the client a chance to discuss her feelings about the examination. Implying that the client is fearful of having an internal examination presupposes that the client is fearful and does not address the client's question. Stating that a slightly uncomfortable internal exam must be performed does not give the client a chance to discuss her feelings about the examination; the nurse is assuming that the client's concerns are related to discomfort.
How does a nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment?
1 Depressed dance reflex 2 Limited adduction of the leg Correct3 Asymmetry of the gluteal folds 4 Shortened leg on the unaffected side The gluteal folds should be symmetric, as should all planes and folds of the body. An abnormality of the hips will cause asymmetry, a shorter leg on the affected side, or both. The dance reflex is not affected in DDH . With DDH, abduction of the leg is usually limited at the hip. The leg on the affected, not unaffected, side appears to be shorter with DDH.
A nurse is assessing a primigravida who was admitted in early labor after her membranes ruptured. She is at 41 weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?
1 Encourage her to watch television Correct2 Take a walk around the unit with her 3 Ask her to maintain a left lateral position 4 Promote the patterned, paced breathing technique Walking may increase the frequency and intensity of the contractions. Although watching TV may be a relaxing activity, it will not help stimulate labor. At this time there is no indication that the client should assume the left lateral position. During early labor, slow chest or abdominal breathing helps the client relax; the patterned, paced breathing technique is more appropriate for the transition phase of labor.
One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next?
1 Encourage the client to void 2 Notify the practitioner immediately 3 Massage the uterus and attempt to express clots Correct4 Continue periodic evaluations and record the findings Immediately after birth the uterus is 2 cm below the umbilicus; during the first several postpartum hours the uterus will rise slowly to just above the level of the umbilicus. These findings are expected, and they should be recorded. Encouraging the client to void is unnecessary; if the bladder is full, the uterus will be higher and pushed to one side. Notifying the health care provider is unnecessary; involution is occurring as expected. Massage is used when the uterus is soft and "boggy"; when the uterus is firm and the expected size, it is not necessary to try to express clots.
A client is scheduled for amniocentesis. What should the nurse do before the procedure?
1 Give the client the prescribed sedative Correct2 Remind the client to empty her bladder 3 Prepare the client for an intravenous infusion 4 Encourage the client to drink three glasses of water An empty bladder reduces the risk of bladder puncture during the procedure. Sedation is not necessary. An intravenous line is not necessary. The client is encouraged to drink three glasses of water before a sonogram, not an amniocentesis.
A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an α-fetoprotein test. She asks the nurse, "What does this test do?" The nurse bases the response on the knowledge that this test can reveal:
1 Kidney defects 2 Cardiac anomalies Correct3 Neural tube defects 4 Urinary tract anomalies The α-fetoprotein test can detect not only neural tube defects but also Down syndrome and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the α-fetoprotein test.
A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?
1 Muscle irritability within 1 hour of birth 2 Neurological signs during the first 24 hours Correct3 Jaundice that develops in the first 12 to 24 hours 4 Jaundice that develops between 48 and 72 hours after birth The development of jaundice in the first 24 hours indicates hemolytic disease of the newborn. Neurological signs may or may not be present during the first 24 hours; they are dependent on the bilirubin level. Muscle irritability may or may not be present during the first 24 hours; usually it develops later. Serum bilirubin is expected to accumulate in the neonatal period because of the short life span of fetal erythrocytes, reaching a level of 7 mg/100 mL the second to third day when jaundice appears (physiological jaundice).
A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?
1 Naloxone (Narcan) 2 Lorazepam (Ativan) Correct3 Meperidine (Demerol) 4 Promethazine (Phenergan) Meperidine (Demerol) is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth. Naloxone (Narcan) is an opioid antagonist that reverses the effects of respiratory depression in the newborn. Lorazepam (Ativan) is a sedative; it does not cause respiratory depression in the newborn, but it does not relieve pain by itself. Promethazine (Phenergan) is a tranquilizer; it does not cause respiratory depression in the newborn. Promethazine does not relieve pain by itself.
What clinical findings does the nurse expect to observe in a newborn with trisomy 21 (Down syndrome)? (Select all that apply.)
1 Large, round eyes 2 Difficulty hearing Correct3 Protruding tongue Correct4 Hypotonic muscle tone 5 Two creases across the palm Correct6 Broad nose with a depressed bridge The eyes appear small because of epicanthic folds on the inner corner of the eyelids and the upward slant of the eyes. Impaired hearing is not an expected problem with Down syndrome. The tongue usually protrudes and is sometimes fissured. Infants with Down syndrome have decreased muscle tone, which compromises respiratory expansion, as well as the adequate drainage of mucus. Usually there is one deep crease across the palm of the hand (simian crease). A broad nose with a depressed bridge (saddle nose) is a characteristic of Down syndrome.
A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take?
Correct1 Discontinuing the test because the pattern is reassuring 2 Encouraging the client to drink more fluids to decrease the fetal heart rate 3 Notifying the primary health care provider and preparing for an emergency birth Incorrect4 Recording this nonreassuring pattern and continuing the test for further evaluation The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn?
Correct1 In utero through the placenta 2 In the postpartum period through breast milk 3 During birth through contact with the maternal vagina 4 After the birth through a blood transfusion given to the mother Toxoplasmosis is caused by a parasitic protozoon that is acquired from inadequately cooked contaminated food or through handling of infected cat feces; the most common form of transmission to the newborn is by way of placental perfusion when in utero. There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not contract toxoplasmosis from the maternal genital tract during the birth process. There is no evidence that toxoplasmosis is transmitted in blood transfused into the mother.
A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as:
Correct1 Milia 2 Lanugo 3 Whiteheads 4 Mongolian spots Milia are common, are not indicative of illness, and eventually disappear. Lanugo is fine, downy hair. Whiteheads are a lay term for milia; the term is not used in documentation. Mongolian spots are bluish-black areas on the buttocks that may be present on dark-skinned infants.
A newborn's hands and feet are cyanotic and there is circumoral pallor when the infant cries or feeds. What should the nurse do?
Correct1 Notify the practitioner, because circumoral pallor may indicate cardiac problems 2 Notify the practitioner, because both signs are indicative of increased intracranial pressure 3 Take no specific action, because both signs are expected in a newborn until 2 weeks of age Incorrect4 Take no specific action, because circumoral pallor is an expected finding for the first 72 to 96 hours Although acrocyanosis (cyanotic hands and feet) is common in the newborn, circumoral pallor is one sign of cardiac pathology and indicates a need for further investigation. Neither circumoral pallor nor acrocyanosis is a sign of increased intracranial pressure. Although acrocyanosis is common in the newborn, circumoral pallor is one sign of cardiac pathology and indicates a need for further investigation. Circumoral pallor is not expected in the newborn; it may indicate cardiac pathology.
A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours later. How does the nurse determine that the uterus is demonstrating appropriate involution?
Correct1 The amount of lochia rubra is moderate. 2 Numerous clots are being passed vaginally. 3 Bleeding from the episiotomy has stopped. 4 Uterine cramps are absent during breastfeeding. Red, distinctly blood-tinged vaginal flow (lochia rubra ) is expected during the first few postpartum days and indicates that involution is progressing as it should. Clots indicate uterine atony, which prevents involution of the uterus. The status of the episiotomy is unrelated to the status of the uterus. Uterine cramps during breastfeeding are evidence that the uterus is undergoing appropriate involution.
What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? (Select all that apply.)
Correct1 Pain management with oral analgesics 2 Continuous application of a warm pack Correct3 Assessment of the site every 15 minutes Incorrect4 Gentle cleansing with antibacterial cleanser Correct5 Application of an ice pack for 20-minute intervals 6 Instructing the client in how to promote normal bowel function Providing pain management will prevent the client's pain from reaching an unmanageable level. Application of ice will decrease pain and edema. Assessment of the site will identify any abnormal changes. Warmth applied to newly traumatized tissue will increase pain and edema. Antibacterial cleanser would be caustic and painful to the laceration. Teaching regarding bowel function would be more appropriately presented after the client has completed the fourth stage and resumed normal intake.
A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? (Select all that apply.)
Correct1 Thin upper lip 2 Wide-open eyes Correct3 Small upturned nose 4 Larger-than-average head Correct5 Smooth vertical ridge in the upper lip The abnormal facies associated with FAS includes a thin upper lip (vermilion), a small upturned nose, and a smooth vertical ridge (philtrum) in the upper lip, all of which are distinctive in these infants. Infants with FAS have small eyes with epicanthic folds, rather than wide-open eyes, as well as microcephaly (head circumference less than the tenth percentile), rather than a larger-than-average head.
A nurse plans to evaluate a postpartum client's uterine fundus for involution. What should the nurse ask the client to do before this assessment?
Drink fluids. Correct2 Empty her bladder. 3 Perform the Valsalva maneuver. 4 Assume the semi-Fowler position. Having the client empty her bladder will help ensure accurate assessment of fundal height. A full bladder may promote a boggy uterus and may elevate the uterus upward and toward the client's right side. There is no need to drink fluids before this assessment; however, the client should drink at least 2 L of fluid a day during the postpartum period. The Valsalva maneuver has no effect on the assessment of fundal height. Assessing the fundus while the client is in the semi-Fowler position will result in an inaccurate assessment. The bed should be flat, and the client should assume the supine position.
A 16-year-old primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria. She gained 50 lb during the pregnancy, and her face and extremities are edematous. What complication, which occurs in the latter part of pregnancy, does the nurse identify? 1 Eclampsia Correct2 Severe preeclampsia 3 Chronic hypertension 4 Gestational hypertension
With severe preeclampsia, arteriolar spasms cause hypertension and decreased arterial perfusion of the kidneys, which in turn cause an alteration in the glomeruli, resulting in oliguria and proteinuria, as well as retention of sodium and water, resulting in edema. Eclampsia is characterized by seizures; there are no data to indicate that the client is having or has had seizures. Chronic hypertension is hypertension diagnosed before pregnancy or before 20 weeks' gestation. If hypertension diagnosed during pregnancy for the first time persists beyond the postpartum period, it is also considered chronic hypertension. Gestational hypertension is hypertension that occurs during midpregnancy for the first time and without proteinuria; it is definitively diagnosed when the hypertension resolves 12 weeks after delivery.