reproduction quiz

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? Conductive Convective Evaporative Radiating

Evaporative Evaporative heat loss occurs with the evaporation of fluid from the infant.

When examining a newborn's eyes, the nurse would expect which assessment? follows your finger a full 180 degrees has a white rather than a red reflex follows a light to the midline produces tears when he cries

follows a light to the midline Newborns do not usually follow past the midline until 3 months of age. They do not tear.

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? increased cervical dilation increased feelings of control less anxiety decreased sedation

less anxiety Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply. lethargy low-pitched cry cyanosis skin rashes jitteriness

lethargy cyanosis jitteriness The nurse should monitor the newborn for lethargy, cyanosis, and jitteriness. Low-pitched crying or rashes on the infant's skin are not signs generally associated with hypoglycemia

A nursing student doing a rotation in labor and birth correctly identifies which medications as most commonly used for tocolysis? Select all that apply. magnesium sulfate atosiban indomethacin nifedipine nitroglycerin

magnesium sulfate atosiban indomethacin nifedipine Medications commonly used for tocolysis include magnesium sulfate, atosiban, indomethacin, and nifedipine. These drugs are used "off label," meaning that they are effective but have not been officially tested and developed for this purpose by the Food and Drug Administration.

The Ballard scoring system evaluates newborns on which two factors? physical maturity and neuromuscular maturity skin maturity and reflex maturity tone maturity and extremities maturity body maturity and cranial nerve maturity

physical maturity and neuromuscular maturity When determining a newborn's gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? redness temperature edema drainage

temperature The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? first degree second degree third degree fourth degree

fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client? administrating IV ephedrine administrating IV naloxone maintaining the client in a supine position starting an IV and hanging IV fluids

starting an IV and hanging IV fluids Prehydration with IV fluids helps to prevent the most common side effect of epidural anesthesia, which is hypotension (20%). If the client develops hypotension or respiratory depression, then IV ephedrine or IV naloxone, respectively, can be administered, but neither is preventative. Maintaining the client in a supine position is recommended for a spinal headache, which can be a side effect of epidural anesthesia but is not the most common side effect and is not preventative

The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? The client states that she is having heavy bleeding. When ambulating the client to the bathroom, a gush of red blood was noted. The client has saturated three sanitary napkins in the past 4 hours. The client has lost 100cc of blood from what I approximate on her clothing.

The client has saturated three sanitary napkins in the past 4 hours. The best way to determine and report the amount of bleeding is by the number of sanitary napkins which have been saturated. This provides a common and measurable way to determine the approximate amount of bleeding. Stating heavy bleeding or a gush of blood is subjective. Determining the amount of bleeding from assessing stained clothing is difficult.

Which statement is false regarding bathing the newborn? To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing should not be done until the newborn is thermally stable. While bathing the newborn, the nurse should wear gloves. Mild soap should be used on the body and hair but not on the face.

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? positive bonding negative bonding positive attachment negative attachment

negative attachment Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? touching talking looking feeding

touching Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client? Turn down oxytocin administration by half. Start administering tocolytic therapy. Assess contractions by using external monitor. Administer hydration and sedation frequently.

Assess contractions by using external monitor. In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention.

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states: "I can continue sitting up after the spinal is given." "I may end up with a severe headache from the spinal anesthesia." "The anesthesia will numb both of my legs to a level above my breasts." "I will need to lie on my right side to reduce vena cava compression."

"I may end up with a severe headache from the spinal anesthesia." Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating headache pain.

How does a woman who feels in control of the situation during labor influence her pain? Feelings of control are inversely related to the client's report of pain. Decreased feeling of control helps during the third stage. There is no association between the two factors. Feeling in control shortens the overall length of labor.

Feelings of control are inversely related to the client's report of pain. Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control.

A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which method should the nurse use to do this? Observe chest movement. Observing and count the pulsations of the umbilical cord. Observe response to a suction catheter in the nostrils. Observe resistance to any effort to extend the newborn's extremities.

Observe chest movement. Respirations are counted by observing chest movement. Reflex irritability may be evaluated by observing response to a suction catheter in the nostrils or response to having the soles of the feet slapped. Heart rate is typically determined by auscultation with a stethoscope but may also be obtained by observing and counting the pulsations of the umbilical cord at the abdomen, if the cord is still uncut. Muscle tone is evaluated by observing resistance to any effort to extend the newborn's extremities.

A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated fetal heart rate (FHR) changes. What intervention should the nurse perform to manage the changes? Assist the client to a supine position. Provide supplemental oxygen. Discontinue intravenous (IV) fluid. Turn the client to her right side.

Provide supplemental oxygen. The nurse should provide supplemental oxygen if a client who has been administered combined spinal-epidural analgesia exhibits signs of hypotension and associated FHR changes. The client should be assisted to a semi-Fowler's position; the client should not be kept in a supine position or be turned on her left side. Discontinuing IV fluid will cause dehydration

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? Use the sealed and chilled milk within 24 hours. Use any frozen milk within 6 months of obtaining it. Use microwave ovens to warm the chilled milk. Refreeze any unused milk for later use if it has not been out more that 2 hours.

Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

The nurse is teaching a group of nursing students about pharmacologic interventions for pain in labor. The teaching has been effective when the students state that complications associated with epidural and spinal anesthesia include which conditions? Select all that apply. pruritis maternal fever hypotension aspiration respiratory depression

pruritis hypotension respiratory depression Hypotension is the most frequent side effect associated with epidural or intrathecal anesthesia. When narcotics are used in addition to anesthetics, pruritus is a common side effect. Respiratory depression is another possible side effect when narcotics are used for spinal and/or epidural anesthesia.

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? "It might take up to a week for your bowels return to their normal pattern." "I'll get a laxative prescribed so that you can move your bowels." "That's unusual. Are you making sure to eat enough?" "Let me call your healthcare provider about this problem."

"It might take up to a week for your bowels return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas to gain additional information. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the healthcare provider is not necessary, and this statement could add to the client's currrent concern.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "If you don't attempt to void, I'll need to catheterize you." "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." "I'll contact your primary care provider." "I'll check on you in a few hours."

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action? "My contractions are really intense now." "My lips and fingers are tingling." "My mouth and lips are so dry." "I feel burning in my perineum."

"My lips and fingers are tingling." When the client reports that her lips and fingers are tinging, the nurse is correct to understand that she is hyperventilating. To correct hyperventilation, the nurse instructs the client to slow the breathing. A paper bag or cupped hands is the correct nursing action. All of the other statements are normal for the client in the transition phase of labor. The nurse would moisten the client's lips or provide a lip balm for dry mouth or lips.

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll turn the mobile on that's hanging above his head in his crib." "We'll lightly rub his back as we talk to him softly." "We'll swaddle him snuggly to make him feel secure." "We'll hold off on feeding him for a while because he might be too full."

"We'll hold off on feeding him for a while because he might be too full." The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? "Followup with your healthcare provider within 3 weeks of being discharged." Notify the healthcare provider if your temperature is greater than 99° F (37.2° C)." "You should be seen by your healthcare provider if you have blurred vision." "Call your healthcare provider if you saturate a peri-pad in less than 4 hours.

"You should be seen by your healthcare provider if you have blurred vision." The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used. +4 station +2 station -2 station 0 station -4 station

-4 station -2 station 0 station +2 station +4 station Explanation: Progressive fetal descent (-5 to +4) is the expected norm during labor, moving downward from the negative stations to zero station to the positive stations in a timely manner.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? 1 week 2 weeks 3 weeks 4 weeks.

2 weeks Once postpartum blues are determined to be the likely cause of her mood symptoms, the nurse can offer anticipatory guidance that these mood swings are commonly experienced and usually resolve spontaneously within a week and offer reassurance. Women should also be counseled to seek further evaluation if these moods do not resolve within two weeks, as postpartum depression may be developing.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? When the infant is 48 hours old 24 hours after the newborn's first protein feeding 36 hours before the infant is discharged home with its parents Just before discharge home

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding

The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data? A blood culture to note any infection of the blood A urine culture to rule out a urinary tract infection An ultrasound to determine fetal age A urine dipstick test to check for protein

A urine dipstick test to check for protein Due to client symptoms suggesting preeclampsia, a urine dipstick test will screen for proteinuria. Proteinuria is commonly found in clients with preeclampsia. There are no other symptoms of an infection in the blood or a urinary tract infection requiring this diagnostic test. An ultrasound may be utilized at some point

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilatation, she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do? Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. Agree with the client, and administer the drug immediately to keep the pain manageable. Explain to the client that narcotics should only be administered an hour or less before birth. Refuse to administer narcotics because they can develop dependency in the client and the fetus.

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. The timing of administration of narcotics in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, narcotics are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Lower rate of urinary tract infections Reduced risk of penile cancer Fewer complications than if done later in life Anesthetic may not be effective during the procedure

Anesthetic may not be effective during the procedure The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? Assess fetal heart sounds. Place the woman in Trendelenburg position. Administer oxygen at 10 L/min by face mask. Administer amnioinfusion.

Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is: At risk for postpartum depression due to inadequate rest. At risk for interruption of tissue integrity. At risk for safety due to low hemoglobin. At risk for inadequate healing due to decreased nutrition.

At risk for postpartum depression due to inadequate rest. This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time

The nursery head nurse is conducting an in-service on prevention of hypoglycemia to her staff. What information would she share with this group? Select all that apply. If a newborn becomes lethargic or sleepy, draw a heel stick blood glucose. Offer glucose feedings to all newborns at 1 hour of age. Encourage breast-feeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns.

Encourage breast-feeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns. To prevent injury from hypoglycemia, hypoglycemia needs to be prevented. Breast-feeding mothers are encouraged to begin feedings early and continue on a frequent basis. Bottle-fed newborns require early feedings as well. Thermoregulation can also help maintain a newborn's blood glucose. Doing a heel stick blood glucose is a good idea for a lethargic newborn but will not prevent hypoglycemia from occurring. Glucose water feedings are no longer recommended.

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist? Dry, cracked lips Urinary retention Rapid progress of labor Inability to push

Inability to push If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? Send a family member to accompany the infant when leaving the room. Check the name on the baby's identification bracelet. Provide a list of approved visitors who came spend time with the infant. Check the identification badge of any health care worker before releasing baby from room.

Check the identification badge of any health care worker before releasing baby from room. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm? Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. Advise that the woman not get out of bed until the nurse returns with assistance. Do nothing, this is normal. Ask the woman what she has had to eat today.

Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. During pregnancy, the distended uterus obstructs the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. Increased stroke volume reduces the pulse rate to between 50 and 70 beats per minute. The nurse should be certain to compare a woman's pulse rate with the slower range expected in the postpartum period, not with the normal pulse rate in the general population. Pulse usually stabilizes to prepregnancy levels within 10 days.

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success? Use of pass codes onto the unit Use of monitor attached to babies Use of cameras at all doors Cooperation by the parents with the hospital policies

Cooperation by the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.

The nurse is monitoring a primipara who has been receiving oxytocin and is now in hypertonic labor. If the nurse notes the fetal heart rate has suddenly dropped, which action should the nurse prioritize? Decrease the oxytocin drip rate. Turn the client on the left side. Administer a tocolytic medication. Assist with McRoberts maneuver.

Decrease the oxytocin drip rate. The client will be receiving oxytocin to induce the labor. An adverse reaction would be a hypertonic uterus, in which the uterine contractions are manifested with increased frequency and intensity. When the infant is showing signs of distress, the nurse should first either stop or decrease the oxytocin drip rate, as per the primary care provider's orders. If this does not stop the contractions, then a tocolytic should be administered to stop the uterus from contracting and improve the fetal status

A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply. Determine the mother's room temperature during the visit. Ask the mother if she fed the newborn while the infant was in the room with her. Turn the nursery temperature up to 80°F (26.7°C). Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door.

Determine the mother's room temperature during the visit. Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door. The newborn's temperature is low and she needs to be warmed up. Placing a cap on her head and wrapping her in a blanket helps the newborn conserve body heat. Determining the maternal room temperature is important to ensure that the newborn was not chilled while out with the mother, and helps determine the cause of the hypothermia. Lastly, placing the crib away from walls and drafts will help prevent heat loss and maintain a thermoneutral environment. Increasing the nursery temperature is not a good idea since this may overheat this newborn as well as other babies in the nursery.

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using? Massage Abdominal imagery Effleurage Pain pathway blockage

Effleurage Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate? It is a normal skin finding in a newborn. It is a sign of a group beta streptocoous skin infection. It is an indication that the woman has mistreated her newborn. It is a self-limiting virus that does not require treatment.

It is a normal skin finding in a newborn. This rash is most likely is erythema toxicum, also known as newborn rash.

The nursery head nurse is conducting an in-service on prevention of hypoglycemia to her staff. What information would she share with this group? Select all that apply. Keep the newborns warm in the nursery and covered with a blanket. Encourage breast-feeding mothers to nurse immediately after delivery. Initiate early feedings for all bottle-fed newborns. Offer glucose feedings to all newborns at 1 hour of age. If a newborn becomes lethargic or sleepy, draw a heel stick blood glucose.

Encourage breast-feeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns. To prevent injury from hypoglycemia, hypoglycemia needs to be prevented. Breast-feeding mothers are encouraged to begin feedings early and continue on a frequent basis. Bottle-fed newborns require early feedings as well. Thermoregulation can also help maintain a newborn's blood glucose. Doing a heel stick blood glucose is a good idea for a lethargic newborn but will not prevent hypoglycemia from occurring. Glucose water feedings are no longer recommended.

A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? Tell her that you will notify the doctor of the unusual pain and see what he wants to do. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Recommend that the client ambulate more to help relieve the pain. Encourage the mother to breast-feed to help relax the uterus.

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Afterpains occur most commonly in multipara mothers and occur when the uterus contracts and relaxes at intervals. Breast-feeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the doctor.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendations would the nurse not make to this mother? Rocking and talking to the infant Swaddling the infant before returning to the crib Feeding the infant more formula whenever she begins to fuss Gently patting or stroking the infant's back

Feeding the infant more formula whenever she begins to fuss Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch and gentle pats on the back all help calm a fussy infant.

A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time? Explain to her that there was probably something wrong with the infant and that is why it died. Offer to take pictures and footprints of the infant once it is delivered. Call the hospital chaplain to talk to the parents. Recommend that she not hold the infant after it is delivered so as to not upset her more.

Offer to take pictures and footprints of the infant once it is delivered. When parents are faced with a fetal death, they need comfort and support without being intrusive. Taking pictures, footprints and gathering other mementos are very important in helping the family deal with the death better. The mother is encouraged to hold the infant after delivery and name it. Telling the parents that the infant was probably defective is hurtful and not supportive to them. Calling the hospital chaplain is something that can be offered but should not be done without the parent's approval.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? Tape electronic thermistor probe to the abdominal skin. Obtain the temperature orally. Place electronic temperature probe in the midaxillary area. Obtain the temperature rectally.

Place electronic temperature probe in the midaxillary area. The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do? Bolus the client with another dose of medication through the epidural. Place the client in a knee-chest position. Turn the client on her left side. Prepare the client for a cesarean birth.

Prepare the client for a cesarean birth. The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth.

The nurse is teaching a couple about the pros and cons of circumcision for their infant son. The nurse knows teaching has been effective when the couple can identify which contraindications to circumcision? Select all that apply. Difficult intravenous access Preterm infant Bleeding disorder Congenital genitourinary disorder Active infection

Preterm infant Bleeding disorder Congenital genitourinary disorder Active infection The procedure is contraindicated in neonates who 1) are still in the transition period; 2) are sick or preterm; 3) have a family history of bleeding disorder until the disorder is ruled out in the neonate; 4) have received a diagnosis of a bleeding disorder; 5) have a congenital genitourinary disorder, such as epispadias or hypospadias. The procedure does not necessitate IV access.

The nurse is teaching discharge instructions to the young parents of a healthy newborn boy, whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered? A yellowish crusty substance on the circumcision site Crying for 2 hours or more each day Redness at the base of the umbilical cord Straining when he is passing stools

Redness at the base of the umbilical cord The cord should dry and fall off in the 7 to 10 days after birth. If the cord base changes color or develops drainage, the health care provider needs to be notified as these could be signs of infection. A yellowish crusty substance on the circumcision site indicates normal healing. Crying for two hours or more each day and straining at stools are normal in a newborn.

Which order by the health care provider would the nurse question if given in the active stage of labor? Ice chips as requested. Secobarbital for relaxation Positioning with pillows Out of bed with assistance

Secobarbital for relaxation A sedative, such as secobarital, is given in early labor to promote sleep or a hypertonic contraction pattern. This class of barbiturates can cause respiratory and central nervous system depression if given within 12 to 24 hours of birth. Ice chips may be provided to decrease symptoms of dry mouth. Providing client positioning with the use of pillows for support may allow the client to relax between contractions. For safety reasons, primarily during an intense contraction, the client needs assistance while out of bed.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response? Suggest a less extreme alternative such as a sedative. Support the client's decision and call the obstetrician. Gently remind the client of her goal of a natural birth and encourage and help her. Ask the husband to gently remind her of their goal of natural birth and to encourage and help her.

Support the client's decision and call the obstetrician. Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

A heel stick blood glucose on a 6-hour-old newborn is 44 but the venous blood sample shows a glucose of 89. What could cause this discrepancy? The bedside glucometer is not calibrated for newborns. The serum blood sugar is falsely high. There was too much blood in the heel stick test strip. The newborn is stressed and is breaking down glycogen quickly.

The bedside glucometer is not calibrated for newborns. The bedside glucometer must be calibrated for newborns to accommodate the high hematocrit concentrations of the newborn. Otherwise, false readings may occur. The other options are not correct—serum blood sugars are not falsely high, too much blood on the test strip will just wipe off, and the newborn is not breaking down glycogen that quickly.

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? The infant requires immediate and aggressive interventions for survival. The infant is adjusting well to extrauterine life. The infant is experiencing moderate difficulty in adjusting to extrauterine life. The infant probably has either a congenital heart defect or an immature respiratory system.

The infant is experiencing moderate difficulty in adjusting to extrauterine life. The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse should not conclude that the infant is in severe distress requiring immediate interventions for survival or has a congenital heart or respiratory disorder. If the Apgar score is 8 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care? The newborn will experience no bleeding episodes lasting more than 5 minutes. The newborn's body temperature will stabilize between 97.8ºF and 99.5ºF (36.6ºC and 37.5ºC). The newborn will be correctly identified prior to separation from the parents. The newborn's blood glucose will remain above 50mg/dL

The newborn will experience no bleeding episodes lasting more than 5 minutes. Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care.

Which assessment finding is most important as labor progresses? The client is remaining in control of emotions. Labor is completed within 18 hours. The uterus relaxes completely between contractions. The pulse and respirations rise with the work of labor.

The uterus relaxes completely between contractions. It is most important that the uterus relaxes completely between contractions. If not, sufficient blood flow to the placenta and oxygen to the fetus may be interrupted. Also, uterine rupture can occur. It is appropriate for the client to remain in control of emotions. The nurse and support person provide emotional support as needed. There is no time frame for labor to be completed. It is normal for the pulse and respiratory rates to increase with the work of labor.

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply. Apply talc powder to the diaper area with each diaper change. Wash the penis with warm water at each diaper change. Fasten the diaper loosely to prevent unnecessary friction as irritation. Report if there is a bleeding spot the size of a dime on the diaper. Notify the doctor if the newborn does not void after 4 hours.

Wash the penis with warm water at each diaper change. Fasten the diaper loosely to prevent unnecessary friction as irritation. Following circumcision, the nurse will monitor the newborn for bleeding, voiding and pain. A spot larger than the size of a quarter, not a dime, is reported to the physician. The penis is washed in warm water with no soap with each void. Diapers are left loose so as to not press in the newly circumcised penis. Talc powder is never used when changing diapers and the newborn is given 12 hours to void before the nurse becomes concerned.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? Perform a 3-minute surgical-type scrub. Wear clean gloves. Use infection transmission precautions. Clean hands with a betadine scrub

Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

There are several women in active labor on the unit. Which woman is at highest risk for developing hypotonic contractions and therefore will need frequent nursing assessments? a 21-year-old primipara woman who does not have a support person with her and is very anxious a 17-year-old primipara requesting more pain medication every 15 to 30 minutes (and not receiving it) even though there is an epidural catheter in place that is working effectively a G4 P3 client who is having twins and wants to experience a "natural birth" a 37-year-old G2 P1 woman being induced whose last ultrasound at 36 weeks' gestation showed oligohydramnios

a G4 P3 client who is having twins and wants to experience a "natural birth" Hypotonic contractions occur during the active phase of labor and tend to occur after the administration of analgesia in a uterus that is overstretched by a multiple gestation or polyhydramnios, or in a uterus that is lax from grand multiparty. Anxiety is not listed as a cause for hypotonic contractions.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? generally within 3 to 6 weeks whenever the couple wishes generally after 12 weeks usually within a couple weeks

an ice pack applied to the perineum Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice.

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? bright red, raised bumpy area noted above the right eye small pink or red patches on the baby's eyelids and back of the neck fine red rash noted over the chest and back blue or purplish splotches on buttocks

bright red, raised bumpy area noted above the right eye A red bumpy area noted above the right eye is a hemangioma and needs further investigation to determine whether the hemangioma could interfere with the infant's vision. They may grow larger during the first year then fade and usually disappear by age 9. Stork bites or salmon patches and blue or purple splotches on buttocks (Mongolian spots) are common skin variations and are not concerning. Erythema toxicum, seen as a fine red rash over the chest and back, is also a normal skin variant that will disappear withn a few days.

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction? lack of cervical dilation past 2 cm fetal buttocks as the presenting part reports of severe back pain contractions most forceful in the middle of uterus rather than the fundus

contractions most forceful in the middle of uterus rather than the fundus Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. 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.

A nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. The health care provider suspects the client has amniotic fluid embolism. What other signs or symptoms would alert the nurse to the presence of this condition in the client? Select all that apply. cyanosis arrhythmia hyperglycemia hematuria pulmonary edema

cyanosis pulmonary edema The nurse should monitor cyanosis and pulmonary edema when caring for a client with amniotic fluid embolism. Other signs and symptoms of this condition include hypotension, cyanosis, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest. Arrhythmia, hematuria, and hyperglycemia are not known to occur in cases of amniotic fluid embolism. Hematuria is seen in clients having uterine rupture.

Certain pharmaceuticals can be used to attain cervical ripening in women who need assistance in cervical ripening. They have also often continued into labor without further agents to stimulate uterine contractions. The nurse is aware that the FDA has approved the use of which medication as a cervical ripening agent? dinoprostone misoprostol oxytocin magnesium sulfate

dinoprostone Dinoprostone is approved by the FDA as the only cervical ripening agent to be used; however, ACOF 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 in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? external cephalic version trial labor forceps birth vacuum extraction

external cephalic version External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? local infiltration epidural block regional anesthesia general anesthesia

general anesthesia General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common? hearing vision genetic-linked skeletal malformations

hearing Hearing loss is the most common birth defect in the United States: one in 1,000 newborns are profoundly deaf, and 3 in 1,000 have some degree of hearing impairment. Newborn hearing screening is required by law in most states. Vision, genetic-linked, and skeletal malformations are other forms of birth defects that can occur

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client? hypotonic contractions hypertonic contractions uncoordinated contractions Braxton Hicks contractions

hypotonic contractions With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg.

During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks? ischial spine ischial tuberosity pubic symphysis cervical os

ischial spine Station is assessed in relation to the maternal ischial spines and the presenting fetal part. These spines are not sharp protrusions but rather blunted prominences at the midpelvis. The ischial spines serve as landmarks and have been designated as zero station.

A maternity nurse is aware that the fetal head is the presenting part in complete extension position. Which type of birth should the maternity nurse anticipate? prolonged labor and possible cesarean birth precipitous labor and birth a normal labor and a spontaneous vaginal birth a forceps-assisted vaginal birth

prolonged labor and possible cesarean birth The attitude of the fetal head is moderate flexion. If there are changes in the fetal attitude (the head), the presenting part is then a larger diameter to the maternal pelvis. This presentation could cause a long labor and possible cesarean birth.

The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe? lower back right upper abdominal quadrant upper left arm right great toe

right upper abdominal quadrant A thermistor probe is taped to the newborn's abdomen, usually in the right upper quadrant. This allows for position changes without having to readjust the probe.

Circumcision is a very personal decision for parents, and the nurse's major responsibility is to inform the parents of the risks and benefits of the procedure. The nurse needs to recognize that this is mainly which type of decision? social decision difficult decision family decision legal decision

social decision The decision to circumcise is often a social one. The discussion involves cultural, religious, medical, and emotional considerations. Nurses must remain unbiased and unemotional as they present the facts to the parents.

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? within 30 minutes after birth, in the birthing area within the first 2 to 4 hours, when the newborn reaches the nursery prior to the newborn being discharged 24 hours after the newborn's birth

within the first 2 to 4 hours, when the newborn reaches the nursery The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? within 30 minutes after birth, in the birthing area within the first 2 to 4 hours, when the newborn reaches the nursery prior to the newborn being discharged 24 hours after the newborn's birth

within the first 2 to 4 hours, when the newborn reaches the nursery The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be.