Prep U Maternal Newborn
A client is expecting her second child in 6 months. During the psychosocial assessment, she says to the nurse, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response? a) "The facility requires these answers of all pregnant clients." b) "A client can develop couvade with any pregnancy." c) "Each pregnancy has a unique psychosocial meaning." d) "A second pregnancy may require more psychosocial adjustment."
"Each pregnancy has a unique psychosocial meaning." Explanation: With each pregnancy, a woman explores a new aspect of the mother role and must reformulate her self-image as a pregnant woman and a mother. The other options don't address the client's feelings. No evidence suggests that a second pregnancy requires more adjustment. Couvade symptoms occur in the father, not the mother.
A pregnant client asks how she can best prepare her 3-year-old son for the upcoming birth of a sibling. The nurse should make which suggestion? a) "Reassure your son that nothing is going to change." b) "Reprimand your son if he displays immature behavior." c) "Tell your son about the childbirth about 1 month before your due date." d) "Involve your son in planning and preparing for a sibling."
"Involve your son in planning and preparing for a sibling."
The hospital where a client plans to give birth asks her to provide signed documents before delivery. The client asks the nurse to explain what an advance directive is. What is the nurse's best response? a) "It provides the labor and delivery unit with the names of persons allowed in the delivery room." b) "It's a legal document that helps establish and verify your health care wishes in the event that you can't speak for yourself or your infant." c) "It instructs the hospital on the type of accommodations you want in the postpartum unit." d) "It isn't a legal document, but it helps to clarify your wishes so that the health care team can prepare to provide the necessary care."
"It's a legal document that helps establish and verify your health care wishes in the event that you can't speak for yourself or your infant."
A client who's 4 months pregnant asks the nurse how much and what type of exercise she should get during pregnancy. How should the nurse counsel her?
"Walk briskly for 10 to 15 minutes daily, and gradually increase this time."
On her second visit to the prenatal facility, a client states, "I guess I really am pregnant. I've missed two periods now." Based on this statement, the nurse determines that the client has accomplished which psychological task of pregnancy? a) Preparing to relinquish the neonate through labor b) Assuming caretaking responsibility for the neonate c) Identifying the fetus as a separate being d) Accepting the biological fact of pregnancy
Accepting the biological fact of pregnancy
Which finding indicates placental detachment?
An abrupt lengthening of the cord
During her first prenatal visit, a client expresses concern about gaining weight. What is the nurse's first action? a) Report the client's concerns to her caregiver. b) Be alert for a possible eating problem and do a further in-depth assessment. c) Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. d) Ask her to come back to the clinic every 2 weeks for a weight check.
Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet.
A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?
Breast sensitivity
A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred?
Complete uterine rupture
A 40-year-old primigravid client with AB-positive blood visits the outpatient clinic for an amniocentesis at 16 weeks' gestation. The nurse determines that the most likely reason for the client's amniocentesis is to determine if the fetus has which of the following?
Down syndrome.
During a visit to the clinic, a pregnant 25-year-old who began prenatal care at 10 weeks' gestation and is now in her third trimester reports frequent constipation. Which of the following suggestions by the nurse would be most helpful?
Eating at least four pieces of fruit daily.
An emergency cesarean delivery is planned for a pregnant client who begins to experience excessive vaginal bleeding soon after admission. When developing this client's plan of care, which of the following would be the priority?
Ensuring availability of replacement blood.
pregnant client comes to the facility for her first prenatal visit. After obtaining her health history and performing a physical examination, the nurse reviews the client's laboratory test results. Which findings suggest iron deficiency anemia? a) Hb 10 g/L; HCT 35% b) Hemoglobin (Hb) 15 g/L; hematocrit (HCT) 35% c) Hb 9 g/L; HCT 30% d) Hb 13 g/L; HCT 32%
Hb 9 g/L; HCT 30%
When assessing a client 1 hour after vaginal birth, the nurse notes blood gushing from the vagina, pallor, and a rapid, thready pulse. What do these findings suggest?
Postpartum hemorrhage
After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which of the following hormones is produced by the placenta? a) Testosterone. b) Progesterone. c) Human chorionic gonadotropin (hCG). d) Estrogen.
Testosterone. Explanation: The placenta does not produce testosterone. Human placental lactogen, hCG, estrogen, and progesterone are hormones produced by the placenta during pregnancy. The hormone hCG stimulates the synthesis of estrogen and progesterone early in the pregnancy until the placenta can assume this role. Estrogen results in uterine and breast enlargement. Progesterone aids in maintaining the endometrium, inhibiting uterine contractility, and developing the breasts for lactation. The placenta also produces some nutrients for the embryo and exchanges oxygen, nutrients, and waste products through the chorionic villi.
A nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to: a) assess the client's readiness to stop. b) help the client develop a plan to stop. c) suggest that the client reduce the daily number of cigarettes smoked by one-half. d) provide the client with the telephone number of a formal smoking cessation program.
assess the client's readiness to stop.
Normal lochial findings in the first 24 hours after birth include: a) the complete absence of lochia. b) a foul odor. c) bright red blood. d) large clots or tissue fragments.
bright red blood. Explanation: Bright red blood is a normal lochial finding in the first 24 hours after birth. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor or absence of lochia may signal infection.
A client, age 39, attends a regular prenatal check-up. She's 32 weeks pregnant. When assessing the client, the nurse should stay especially alert for signs and symptoms of: a) cephalopelvic disproportion. b) sexually transmitted diseases (STDs). c) iron deficiency anemia. d) gestational hypertension.
gestational hypertension.
A nurse is doing an assessment of a pregnant client who states that she smokes one pack of cigarettes each day. The nurse should: a) insist that the client stop smoking immediately for the health of her baby. b) inform the client of the risks to the fetus and ask if she'd like a referral to a smoking cessation support group. c) ask the client to cut down to half a pack a day. d) do nothing; smoking is a personal decision.
inform the client of the risks to the fetus and ask if she'd like a referral to a smoking cessation support group.
A client who's 7 weeks pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client's care, the nurse anticipates informing her that if she doesn't stop smoking, her fetus may be at risk for: a) tetralogy of Fallot. b) low birth weight. c) spina bifida. d) hydronephrosis.
low birth weight.
A multiparous client is admitted to the labor and delivery area with painless vaginal bleeding. Ultrasonography shows that an edge of her placenta meets but doesn't occlude the rim of the cervical os. This finding suggests:
marginal placenta previa.
A nurse receives the result of a pregnant client's human immunodeficiency virus (HIV) testing. When the nurse attempts to notify the client of the results, she can't locate her. The nurse should: a) send a registered letter asking the client to contact the clinic. b) send a letter informing the client of the test results. c) leave a message on the answering machine at the client's home. d) give the results to the client's significant other.
send a registered letter asking the client to contact the clinic.
A client who is in her third trimester presents at the labor and delivery triage area. She has bruising on her back and arms and is experiencing bright red vaginal bleeding. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to:
the social worker on call.
During the fourth stage of labor, the client should be assessed carefully for:
uterine atony.
A client at 12 weeks' gestation tells the nurse that she is a vegetarian and eats "lots of rice." To help meet the client's need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following? a) Yogurt. b) Beans. c) Soy milk. d) Corn.
Beans
When caring for the pregnant client with hyperemesis gravidarum, the nurse would further assess the client for which of the following? a) Pinkish vaginal discharge. b) Leaking amniotic fluid. c) Dehydration. d) Abdominal pain.
Dehydration
An 18-year-old pregnant woman tells the nurse that she's concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn't provide insurance. The nurse should recognize that the client: a) needs to take up a second job. b) should be referred to community resources available for pregnant women. c) may not be fit to take care of a child. d) may not take care of herself.
should be referred to community resources available for pregnant women.
A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that: a) "Folic acid is needed to promote blood clotting and collagen formation in the newborn." b) "Folic acid consumption helps with the absorption of iron during pregnancy." c) "Folic acid is important in preventing neural tube defects in newborns and preventing anemia in mothers." d) "Eating foods with moderate amounts of folic acid helps regulate blood glucose levels."
"Folic acid is important in preventing neural tube defects in newborns and preventing anemia in mothers."
A 40-year-old client who is quite anxious says that she would "rather die than be pregnant." Which of the following responses by the nurse is most helpful? a) "Try not to worry until after the pregnancy test." b) "You know, pregnancy is a normal event." c) "I see you're upset. Take some deep breaths to relax a little." d) "You're only 40 years old and not too old to have a baby."
"I see you're upset. Take some deep breaths to relax a little."
Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? a) "What is your expected due date?" b) "Who will be with you during labor?" c) "Do you have any chronic illnesses?" d) "Do you have any allergies?"
"What is your expected due date?" Explanation: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons.
A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean birth may be necessary?
Fetal heart rate of 80 beats/minute
A client calls to schedule a pregnancy test. The nurse knows that most pregnancy tests measure which hormone? a) Human placental lactogen b) Estradiol c) Human chorionic gonadotropin (hCG) d) Human chorionic thyrotropin
Human chorionic gonadotropin (hCG)
The primary health care provider orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?
Lecithin-sphingomyelin (L/S ratio).
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: a) milk and ice pops. b) decaffeinated coffee and scrambled eggs. c) tea and gelatin dessert. d) apple juice and oatmeal.
tea and gelatin dessert.
A client who's been treated for infertility is now pregnant. During a routine ultrasound at 8 weeks' gestation, she learns that five fetuses are visualized. Concerned that five infants wouldn't survive and that his wife couldn't handle the stress of the pregnancy, the client's husband asks the nurse about selective reduction. What is the nurse's best response? a) "You should be glad your wife conceived." b) "Selective reduction has been used to decrease the possibility of complications during pregnancy and birth. I'll ask the physician to speak with both of you." c) "That choice is your wife's because only she is carrying the babies." d) "Why would you consider such a procedure?"
"Selective reduction has been used to decrease the possibility of complications during pregnancy and birth. I'll ask the physician to speak with both of you."
A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe level of alcohol intake for this client? a) "The client consumes no alcohol." b) "The client consumes no more than 2 oz of alcohol daily." c) "The client consumes 2 to 6 oz of alcohol daily, depending on body weight." d) "The client consumes no more than 4 oz of alcohol daily."
"The client consumes no alcohol."
After teaching a primigravid client at 10 weeks' gestation about the recommendations for exercise during pregnancy, which of the following client statements indicates successful teaching? a) "Sitting in a hot tub after exercise will help me to relax." b) "While pregnant, I should avoid contact sports." c) "Even though I'm pregnant, I can learn to ski next month." d) "While we are on vacation next month, I can continue to scuba dive."
"While pregnant, I should avoid contact sports."
A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has oxytocin (Pitocin) infusing. Which response by the nurse is best? a) "You'll have to wait until the oxytocin is infused." b) "You'll have to wait until the vaginal bleeding stops." c) "You may get up to the bathroom whenever you need to." d) "You may use the bathroom with my assistance."
"You may use the bathroom with my assistance."
A 24-year-old nulligravid client with a history of irregular menstrual cycles visits the clinic because she suspects that she is "about 6 weeks pregnant." An ultrasound is scheduled in 2 weeks. The nurse should instruct the client that this test will be done to: a) Identify the gender of the fetus. b) Assess of maternal pelvic adequacy. c) Determine a multifetal pregnancy. d) Assess gestational age.
Assess gestational age.
A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 grams per hour. To maintain safety for this client, the priority intervention is to: a) Assess reflexes, clonus, visual disturbances, and headache. b) Monitor maternal liver studies every 4 hours. c) Maintain continuous fetal monitoring. d) Encourage family members to remain at bedside.
Assess reflexes, clonus, visual disturbances, and headache.
A 19-year-old primipara who delivered a viable male neonate 2 hours ago has decided to breastfeed. Her 22-year-old husband supports her decision. The client tells the nurse, "My mother breastfed all of her children, but I'm going to need lots of help with breastfeeding. I'm worried that I won't be able to do this." What additional information should the nurse obtain prior to teaching the client about breastfeeding? a) Assess her body-to-fat ratio and nutritional status before beginning breastfeeding. b) Determine the client's level of motivation to breastfeed. c) Ask the client if she has read any literature about breastfeeding. d) Perform a complete physical examination to determine her need for help.
Determine the client's level of motivation to breastfeed. Explanation: Successful breastfeeding depends on the client's willingness and motivation to breastfeed. Women who have a strong desire to breastfeed tend to continue breastfeeding longer and are often more tolerant of the discomforts of breastfeeding and more accepting of the need for frequent feedings. Although obtaining information about what the client has read about breastfeeding may provide clues about the client's knowledge level, the type of literature is not a significant factor in successful breastfeeding. A complete physical examination is not necessary. The client is asking for support and assistance with breastfeeding. Performing a physical examination does not provide this needed support. Although adequate nutrition during lactation is important, even clients who have had poor nutrition can be taught how to improve their diets. Assessing the client's body-to-fat ratio is not important for breastfeeding because it is not associated with the mother's ability to breastfeed or the amount of breast milk produced.
A neonate weighing 1870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 has received sodium bicarbonate intravenously. The drug has been effective if the neonate: a) Develops respiratory alkalosis. b) Does not go into metabolic acidosis. c) Is not dehydrated. d) Does not become edematous.
Does not go into metabolic acidosis. Explanation: Metabolic acidosis results from the metabolic changes associated with cold stress. End products of metabolism increase the acidity of the blood, evidenced by a pH of 7.11. Therefore, sodium bicarbonate, which is a buffer base, is often used. Diuretics, not sodium bicarbonate, would be used to combat edema. Intravenous fluids would be used to treat dehydration. Respiratory alkalosis results from excessive carbon dioxide loss, a condition that would be unusual in this neonate. Additionally, because sodium bicarbonate is a base, administering it to client with alkalosis would only further exacerbate the alkalotic condition.
Which document states that clients have a right to confidentiality of medical records and a right to privacy limiting access to that information to health care providers associated with their care. a) Health care power of attorney b) Health Insurance Portability and Accountability Act (HIPAA) c) American Nurses Association Code for Nurses d) Living will
Health Insurance Portability and Accountability Act (HIPAA)
A nurse asks a pregnant client about her alcohol use. The client admits she sometimes has several glasses of wine with dinner. Her alcohol consumption puts her fetus at risk for which condition? a) Alcohol addiction b) Anencephaly c) Learning disability d) Down syndrome
Learning disability
A nurse is caring for a client who is scheduled for amniocentesis. What information about the procedure should the nurse provide before the client signs the consent form?
Name of procedure, how it's performed, description of alternate methods available, potential risk to mother and fetus, risks associated if the procedure isn't performed
A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color? a) Pink b) Yellow c) Green d) Blue
Nitrazine paper turns blue on contact with alkaline substances such as amniotic fluid. Normal vaginal discharge and urine are acidic and cause nitrazine paper to turn pink.
A nurse obtains the antepartum history of a client who's 6 weeks pregnant. Which finding is a concern? a) The client's practice of taking a multivitamin supplement daily b) The client's consumption of four to six small meals daily c) The client's consumption of six to eight cans of beer on weekends d) The client's participation in low-impact aerobics three times per week
The client's consumption of six to eight cans of beer on weekends
A 24-year-old primigravid client who delivers a viable term neonate is ordered to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?
The cord lengthens outside the vagina.
During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. Which of the following should the nurse do next? a) Report the neonate's cyanosis to the primary care provider promptly. b) Wrap the neonate in a warm blanket. c) Keep the neonate in an isolation incubator for at least 2 hours. d) Ask the mother to massage the neonate's hands and feet.
Wrap the neonate in a warm blanket. Explanation: The neonate is demonstrating acrocyanosis, a normal finding evidenced by bluish hands and feet due to the neonate being cold or poor perfusion of the blood to the periphery of the body. The most appropriate action is to wrap the neonate in a warm blanket or place the neonate under a radiant warmer. Massaging the extremities is inappropriate because it will not help to improve the circulation. Keeping the neonate in an isolation incubator is not warranted because acrocyanosis is not an infection but rather a manifestation of the neonate's sluggish peripheral circulation. Because acrocyanosis is a normal finding, notifying the primary care provider is not necessary.
During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to: a) exercise 1 hour before each meal. b) take a vitamin and mineral supplement. c) divide daily food intake into five or six meals. d) eat three well-balanced meals per day.
divide daily food intake into five or six meals. Explanation: To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue.
A client who had a Pap smear 2 months ago and is now beginning oral contraceptives tells the nurse that her menstrual flow has decreased since taking the oral contraceptives. The nurse should tell the client to: a) Request a consultation with an endocrinologist. b) Have her health care provider write a prescription for a lower dosage of oral contraceptives. c) Ask her primary care provider about having another Pap smear. d) Continue to take the oral contraceptives, decreased menstrual flow is normal.
Continue to take the oral contraceptives, decreased menstrual flow is normal.
A client asks, "Can my partner and I still engage in sexual intercourse while I'm pregnant?" The nurse should tell the client: a) "Refrain from having sexual intercourse when you are in the last trimester." b) "Although your sexual desire may change, intercourse is safe during an uncomplicated pregnancy." c) "You should avoid having s intercourse until you are at least 16 weeks pregnant." d) "Throughout the pregnancy, coitus interruptus is the preferred method for sexual activity."
"Although your sexual desire may change, intercourse is safe during an uncomplicated pregnancy."
A client has come to the clinic for her first prenatal visit. The nurse should include which statement about using drugs safely during pregnancy in her teaching? a) "Consult with your health care provider before taking any medications." b) "Medications that are available over the counter are safe for you to use, even early on." c) "During the first 3 months, avoid all medications except ones ordered by your caregiver." d) "All medications are safe after you've reached the 5th month of pregnancy."
"Consult with your health care provider before taking any medications."
A multiparous client 48 hours postpartum who is breast-feeding tells the nurse, "I'm having a lot of cramping. This didn't happen when I nursed my first baby." Which of the following would be the nurse's best response? a) "I will notify your doctor. It's possible there are some placental fragments remaining." b) "The cramping is normal and is caused by your baby's sucking, which stimulates the release of oxytocin." c) "I need to check your lochial flow. You may have a clot that is being dislodged." d) "You must have gotten a heavy dose of oxytocin (Pitocin). It should wear off soon."
"The cramping is normal and is caused by your baby's sucking, which stimulates the release of oxytocin." Explanation: The cramping is caused by the baby's sucking and subsequent stimulation for the release of oxytocin. This cramping is normal. With each subsequent pregnancy, the uterus becomes "stretched" and the release of oxytocin causes the uterus to contract, resulting in the feeling of cramping. Continued moderate to large amounts of lochia rubra is indicative of retained placental fragments. Cramping indicates that the uterus is contracting and most likely firm. A boggy uterus, continued moderate to heavy lochia, mild vasoconstriction, and restlessness and anxiety suggest delayed postpartum hemorrhage due to subinvolution of the placental site, retained placental tissue, or infection. Most clients receive a standard dose of oxytocin (Pitocin) after delivery. Oxytocin has a duration of action of 60 minutes. Therefore, the effects of the drug would have worn off by 24 hours postpartum.
A 19-year-old primigravida at 38 weeks' gestation, in active labor for the past 8 hours, is admitted to the hospital accompanied by her mother. On admission, the client's cervix is 5 cm dilated, her blood pressure is 120/84 mm Hg, and she is breathing rapidly, complaining of feeling dizzy and lightheaded. The nurse determines that the client is most likely experiencing effects of which of the following?
Hyperventilation. Explanation: When a client is hyperventilating during labor, she is eliminating more carbon dioxide than usual. As a result, she becomes lightheaded or dizzy. Being lightheaded or dizzy is not correlated with rapid cervical dilation. The client's complaints are not related to an elevated blood pressure. Being lightheaded or dizzy is not correlated to excitement about the labor process.
When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan? a) The circulating fibrinogen level decreases as much as 50% during pregnancy. b) The temperature decreases slightly early in pregnancy. c) The anterior pituitary gland secretes oxytocin late in pregnancy. d) Cardiac output increases by 25% to 50% during pregnancy.
Cardiac output increases by 25% to 50% during pregnancy. Explanation: During pregnancy, the circulatory system undergoes tremendous changes. Cardiac output increases by 25% to 50%, and circulatory blood volume increases by about 30%. The client may experience transient hypotension and dizziness with sudden position changes. Early in pregnancy there is a slight increase in the temperature, and clients may attribute this to a sinus infection or a cold. The client may feel warm, but this sensation is transient. The level of circulating fibrinogen increases as much as 50% during pregnancy, probably because of increased estrogen. Any calf tenderness should be reported, because it may indicate a clot. Late in pregnancy, the posterior pituitary gland secretes oxytocin. The client may experience painful Braxton Hicks contractions or early labor symptoms.
A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which of the following would the nurse include when teaching the mother about neonatal strabismus? a) Neonates commonly lack eye muscle coordination. b) The neonate is able to fixate on distant objects immediately. c) The neonate's eyes are unable to focus on light at this time. d) Congenital cataracts may be present.
Neonates commonly lack eye muscle coordination. Explanation: Convergent strabismus is common during infancy until about age 6 months because of poor oculomotor coordination. The neonate has peripheral vision and can fixate on close objects for short periods. The neonate can also perceive colors, shapes, and faces. Neonates can focus on light and should blink or close their eyes in response to light. However, this is not associated with strabismus. An absent red reflex or white areas over the pupils, not strabismus, may indicate congenital cataracts. Most neonates cannot focus well or accommodate for distance immediately after birth.
A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean delivery. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following? a) Lengthy and prolonged second stage of labor. b) Moderate fundal massage after delivery. c) Overdistention of the uterus from hydramnios. d) Trauma during labor and delivery.
The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and delivery can also contribute to uterine atony during the postpartum period. Trauma during labor and delivery is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean delivery for breech presentation. Therefore, it is unlikely that she had a long labor.
A 25-year-old primiparous client who delivered 2 hours ago has decided to breastfeed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? a) Keeping plastic liners in the brassiere to keep the nipple drier. b) Removing any remaining milk left on the nipple with a soft washcloth. c) Smoothly pulling the nipple out of the mouth after 10 minutes. d) Placing as much of the areola as possible into the baby's mouth.
Neonates commonly lack eye muscle coordination. Explanation: Convergent strabismus is common during infancy until about age 6 months because of poor oculomotor coordination. The neonate has peripheral vision and can fixate on close objects for short periods. The neonate can also perceive colors, shapes, and faces. Neonates can focus on light and should blink or close their eyes in response to light. However, this is not associated with strabismus. An absent red reflex or white areas over the pupils, not strabismus, may indicate congenital cataracts. Most neonates cannot focus well or accommodate for distance immediately after birth.
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time? a) Walking around in the hallway. b) Sitting in a comfortable chair for a period of time. c) Resting in the right lateral recumbent position. d) Lying in the left lateral recumbent position.
Walking around in the hallway. Explanation: Most authorities suggest that a woman in an early stage of labor should be allowed to walk if she wishes as long as no complications are present. Birthing centers and single-room maternity units allow women considerable latitude without much supervision at this stage of labor. Gravity and walking can assist the process of labor in some clients. If the client becomes tired, she can rest in bed in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent position improves circulation to the fetus.
While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer an ordered hepatitis B intramuscular injection at 4 hours after birth. Which of the following actions should the nurse do first? a) Apply clean gloves before administering the medication. b) Place the neonate under a radiant warmer. c) Wash the injection site with povidone-iodine (Betadine) solution. d) Bathe the neonate with an antibacterial soap.
Apply clean gloves before administering the medication. Explanation: As part of standard precautions, the nurse should don a pair of clean gloves. Additionally, the site is cleaned thoroughly with an alcohol swab before the skin is injected. Sterile gloves are not necessary. Bathing the neonate is not necessary before giving the injection. Some research suggests that bathing removes the neonate's protective skin oils. Placing the neonate under the radiant warmer is not necessary unless the neonate's temperature is subnormal. The neonate's temperature has usually stabilized by 4 hours of age. Washing the injection site with povidone-iodine before giving the injection is not necessary because of the risk for possible allergy to iodine preparations.
The nurse hears a pregnant client yell, "Oh my! The baby's coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate's head is delivering. Which of the following should the nurse do first? a) Advise the mother that help is on the way. b) Tell the client to bear down with force. c) Check for presence of a cord around the neck. d) Suction the mouth with two fingertips.
Check for presence of a cord around the neck. Explanation: In an emergency in which the neonate's head is already delivering, the first action by the nurse should be to check for the presence of a cord around the neonate's neck. If the cord is present, the nurse should gently remove it from around the neck. The mother should be told to breathe gently and avoid forceful bearing-down efforts, which could lead to lacerations. Although blood and bodily fluid precautions are always present in client care, this is an emergency. If possible, the nurse should put on gloves. Suctioning the mouth can be done after the nurse has checked that the cord is not around the neonate's neck. Telling the mother that help is on the way is not reassuring because emergency medical technicians may take some time to arrive. Delivery is imminent because the neonate's head is delivering.
A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? a) Invite everyone into the large conference room to see the neonate. b) Discuss the unit's policy with the charge nurse. c) Teach the grandparents how to scrub and gown before entering the nursery. d) Notify security because the neonate's father is demanding to see his baby.
Discuss the unit's policy with the charge nurse. Explanation: Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the neonate's parents are married or if the mother is an emancipated minor. Therefore, the adolescent mother may not be able to legally make her own decisions about her parents' (the baby's grandparents') presence. She or her parents do have a say as to whether the father's parents can visit. The mother of the neonate does have a say in visitors seeing her baby. Because the family dynamics aren't clear in this scenario, the best answer would be to check with the charge nurse who knows the unit's policy. Although the neonate's father may have demanded to see the baby, the question doesn't indicate violent or threatening behavior; therefore, notifying security isn't necessary. The nurse can instruct the father's parents on how to gown and glove before visiting the neonate if they have permission to visit. Because the family dynamics aren't known, inviting everyone to gather in a conference room isn't advisable.
