RQ 2 - Davis 19 & 20
The labor nurse observes a sinusoidal FHR pattern on the monitor. How should the nurse interpret this?
This may indicate severe fetal anemia - a sinusoidal pattern, which is regular, smooth, undulating, and uncommon, classically occurs with severe fetal anemia as a result of abnormal perinatal conditions.
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn't feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900mL of urine?
"A decreased sensation of bladder filling is normal after childbirth" - the nurse should explain about the decreased sensation of bladder filling after childbirth. It is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling.
Two hours after delivery, the mother tells the nurse that she will be bottle feeding. She asks what she can do to prevent the terrible pain experienced when her milk came in with her last baby. Which response by the nurse is most appropriate?
"I can help you put on a supportive bra; wear one constantly for 1 to 2 weeks" - wearing a supportive, well-fitting bra within 6 hours after birth can suppress lactation. The bra should be worn continuously, except for showering, until lactation is suppressed (usually 7 to 14 days)
The nurse explained the process of cervical effacement to the client in early labor. Which statement indicates that she understands the information?
"The cervix will pull or draw up and become paper thin" - in cervical effacement, the cervix progressively changes from a thick and long structure to paper thin. This statement indicates that the client understands the information.
The client in labor is requesting water therapy (hydrotherapy) to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/-2. How should the nurse respond to the client's request?
"Usually we initiate hydrotherapy during active labor" - Hydrotherapy is usually initiated when the client is in active labor, at approximately 4 or 5 cm. This timing will help reduce the risk of prolonged labor and provide a welcome change when the contractions are becoming stronger and closer together.
While assessing the postpartum client who is 10 hours post-vaginal delivery, the nurse notes a perineal pad that is totally saturated. To determine the significance of this finding, which question should the nurse ask the client first?
"When was the last time you changed your pad?" - the amount of lochia on a perineal pad is influenced by the individuals client's pad changing practices. Thus, the nurse should ask about the length of time the current pad has been in place before making a judgment about whether the amount is concerning.
The caucasian postpartum client asks the nurse if the stretch marks (striae gravidarum) on her abdomen will ever go away. Which response by the nurse is most accurate?
"Your stretch marks will fade to pale white over the next 3 to 6 months"
the client, who is 12 days postpartum, telephones the clinic and tells the nurse that she is concerned that she may have an infection because her vaginal discharge has been creamy white for 2 days now. Which response is correct by the nurse?
"a creamy, white discharge 10 days postpartum is normal" - this is normal 10 to 21 days postpartum. Her lochia changed color on her 10th day postpartum.
the client with mastitis asks the nurse if she should stop breastfeeding because she has developed a breast infection. Which response by the nurse is best?
"continuing to breastfeed will decrease the duration of your symptoms" - recommended with clients who have mastitis. if the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased
SELECT ALL: the home care nurse is visiting the mother and her 6 day old son. the nurse observes that the infant is sleeping in a crib on his back and has a blanket draped over his body. the mother has been sleeping in a nearby room. which statements are appropriate for the nurse to make in response to this situation?
"i am glad to see you are sleeping while your baby sleep" "having your baby sleep on his back reduces the risk of SIDS" "position your baby on his tummy and side while he is awake"
SELECT ALL: the nurse educates the breastfeeding client diagnosed with mastitis. the nurse evaluates that the client has an adequate understanding of how to prevent mastitis in the future when the client makes which statements?
"incorrect latch of my baby can lead to mastitis" "i should perform hand hygiene before i breastfeed" "i should allow my nipples to air-dry after breastfeeding"
the primiparous client, who is bottle feeding her infant, asks the nurse when she can expect to start having her menstrual cycle again? Which response by the nurse is most accurate?
"most women who bottle feed can expect their period within 6 to 10 weeks post-birth" - in non-lactating women, the average time to first ovulation is 45 days, and the return of menstruation usually happens within 6 to 10 weeks post-birth
SELECT ALL: the client, who had a vaginal delivery 18 hours ago, asks the nurse how she should take care of her perineal laceration. Which statements by the nurse are appropriate?
"once home, use a warm sitz bath to sooth your perineum" "use your peri-bottle to apply water to the perineum after each void" "wash your perineum with mild soap at least once each 24 hours" "check your perineum for foul odor or increased redness, heat or pain"
The nurse is caring for the client in labor. Which assessment finding would help the nurse determine whether the client is in the third stage of labor?
Lengthening of fetal cord - the third stage of labor lasts from birth of the baby until the placenta is expelled. Lengthening of the fetal cord is one of several signs indicating placental separation.
the nurse asks the 12 hour postpartum client, who is breastfeeding her baby now, why she has not yet received a dinner tray. the client states that her mother is bringing curry and that she won't be eating the hospital food tonight. Which response by the nurse is best?
"please let me know if you change your mind, i can order food for you later" - many clients have culturally based beliefs about food and beverages that should be consumed in the postpartum period. unless contraindicated, nurses should support and encourage women to incorporate food preferences with cultural significance into their postpartum diet.
the postpartum client, who is 24 hours post-vaginal birth and breastfeeding, asks the nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the nurse is correct?
"simple abdominal and pelvic exercises can begin right now" - on the first postpartum day, the client should be taught to start abdominal breathing and pelvic rocking. Kegel exercises, which should have been taught during pregnancy, should be continued. Simple exercises should be added daily until, by 2 to 3 weeks postpartum, the mother should be able to do sit-ups and leg raises.
the postpartum client is being discharged to home with streptococcal puerperal infection. the client is taking antibiotics but asks the nurse what precautions she should take at home to prevent spreading the infection to her husband, newborn, and toddler. Which is the best response by the nurse?
"wash your hands before caring for your children and after toileting and perineal care" - other than hand hygiene, no additional precautions need to be taken by the client in her home
the postpartum client's blood type is A negative, and her newborn infant's blood type is AB negative. The client received RhoGAM in her second trimester and another dose in her third trimester after a minor car accident. the client is preparing for discharge and asks the nurse when she will receive her RhoGAM injection. The nurse correctly responds with which statement?
"you and your baby have negative blood types; a dose of RhoGAM is not needed" - RhoGAM is administered to women with Rh negative blood types at approximately 28 weeks of gestation and again after any trauma, such as a car accident or fall. After delivery, RhoGAM is only indicated if the newborn has a positive blood; both the client and newborn are Rh negative
the nurse is teaching the client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?
"you may need to use lubrication when resuming sexual intercourse" - low estrogen levels in the early postpartum period causes vaginal dryness
the client who is 20 days postpartum, telephones the perinatal clinic to tell the nurse that she is having heavy, bright red bleeding since hospital discharge 18 days ago. Which instruction to the client is correct?
"you need to come to the clinic immediately" - lochia rubra that persists for longer than 2 weeks is suggestive of sub-involution of the uterus, which is the most common cause of delayed postpartum hemorrhage. the client should be seen in the clinic immediately to determine what is causing her abnormal lochia discharge.
A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What APGAR score would the nurse document for this newborn?
1 pt for HR (below 100) 2 pt for good cry (respiratory effort) 2 pt for well flexed (muscle tone) 2 pt for good reflex irritability (reflex response) 1 pt for pink body and blue extremities (color)
SELECT ALL: The client on the labor unit has been experiencing frequent, painful contractions for the last 6 hours. The contractions are of poor quality, and there has been no cervical change. Which interventions should the nurse implement.
Maintain bedrest Administer sedative Administer an analgesic Prepare to start oxytocin
The nurse is assessing the client who is in the active stage of labor. Which is the most crucial information that the nurse should assess related to the client's ethnicity and stage of labor?
Choice of pain control measures - because cultural variations exist in pain control measures used and pain tolerance, the most crucial assessment in the active stage of labor is the client's choice of pain control measures.
The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?
Initiate a low-dose oxytocin IV infusion - the nurse should question the administration of oxytocin (Pitocin). Oxytocin is used for stimulating contraction of the uterus. Uterine contractions can cause further umbilical cord compression.
An LPN asks an RN to assist in locating the fundus of the client who is 8 hours post-vaginal delivery. Where should the RN direct the LPN to begin to palpate the fundus?
6-12 hours after birth, the fundus of the uterus rises to the level of the umbilicus due to blood and clots that remain within the uterus and changes in ligament support. Thus the RN should direct the LPN to locate the client's fundus at the level of the umbilicus
The nurse is caring for two maternity clients who are in labor. The nurse determines that head entrapment is most likely to occur with which delivery presentation?
A breech delivery is most likely to be associated with head entrapment because the head is the largest part of the fetal body, and it is delivered last in a breech delivery.
The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase?
Latent phase - during the latent phase (1-3cm) , the client is usually happy and talkative.
The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?
An increase in maternal HR - maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume
The nurse is caring for multiple clients. The nurse determines that which client would be a candidate for intermittent fetal monitoring during labor?
The primigravida client at 41 weeks - the client is overdue by 7 days but has a reassuring FHR pattern is able to have intermittent fetal monitoring.
The laboring client's amniotic membranes have just ruptured. Which nursing action should be priority?
Assess the FHR pattern - the priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well-being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR.
ORDER OF ACTION: The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse's interventions in the sequence that they should occur.
Assist the client into a different position Administer oxygen via facemask Increase the rate of IV fluids Have the HCP paged if the prolonged decelerations have not resolved Prepare for vaginal examination and fetal scalp stimulation Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low
SELECT ALL: The nurse is caring for the low-risk client during the first stage of labor. When should the nurse assess the FHR pattern?
Before administering medications After vaginal examinations
The nurse's laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last two hours, the baseline has decreased to the 100s. How should the nurse document this FHR?
Bradycardia - An FHR baseline less than 110 is classified as bradycardia
The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?
Check that there is adequate gel under the transducer and reposition - When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem.
The laboring multigravida client's last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
Complete another vaginal exam - the nurse should first evaluate labor progress by performing another vaginal exam. Previously, the client was almost fully effaced (90%), and the fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part.
SELECT ALL: The laboring client just had a convulsion after being given regional anesthesia. Which interventions should the nurse implement?
Establish an airway Provide 100% oxygen Administer diazepam Page the anesthesiologist STAT
The nurse administers butorphanol tartrate to the client in active labor. What is the nurse's most important action to help prevent side effects from the medication?
Evaluating maternal VS and pulse ox - would determine changes in respiratory and cardiac status. Respiratory depression in both the mother and fetus can occur with butorphanol tartrate (Stadol)
The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal?
Has a pH of 7.1 - the pH of amniotic fluid is usually between 6.5 and 7.5, which is more alkaline than urine or purulent material.
SELECT ALL: the laboring client is experiencing problems, and the nurse is concerned about possible side effects from the epidural anesthetic just administered. Which problems should the nurse attribute to the epidural anesthetic?
Has breakthrough sharp pain Has a pounding headache Unable to feel a full bladder Has an elevated temperature
Which breast appearance shows that the client is experiencing symptoms associated with poor latch?
If proper latch is not obtained during breastfeeding, the newborn's sucking may cause nipple cracking, blistering, and bleeding
SELECT ALL: the client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client's deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. What should be the nurse's plan?
Notify the client's HCP about the reduced DTRs Prepare to administer calcium gluconate IV Assess the level of consciousness and vital signs
The pregnant client arrives at the triage unit. The nurse assesses that she is at 4/50/-1 and that the FHR is 148. What priority information should the nurse collect before proceeding?
Number of weeks' gestation - knowing the weeks gestation is most important because if she is in premature labor, she may need to be given tocolytics to stop the process and to ensure adequate fetal lung maturity. if she is full term, the labor process could continue.
ORDER OF ACTION: the nurse's laboring client presents with ruptured membranes, frequent contractions, and bloody show. She reports a greenish discharge for 2 days. Place the nurse's actions in the order that they should be completed.
Obtain FHT first Perform a sterile vaginal exam Assess the client thoroughly Notify the HCP
The nurse is unable to determine the fetal position for the laboring client who is morbidly obese. What should the nurse plan to obtain the most accurate method of determining fetal position in this client?
Perform transabdominal US - Real-time transabdominal ultrasound is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, present
The full term pregnant client presents with bright red vaginal bleeding and intense abdominal pain. Her BP is 150/96mmHg and her pulse is 109bpm. The nurse should immediately implement interventions for which potential complication?
Placental abruption - This occurs when the placenta separates from the uterine wall before the birth of the fetus. It is commonly associated with preeclampsia.
The nurse is reviewing laboratory results of the client in labor prior to her receiving epidural anesthesia. Which result is most important to report to the HCP prior to the initiation of the epidural?
Platelets: 100,000/mm^3 - the nurse should report the low platelet count of 100,000/mm^3 (normal is 150,000 to 450,000mm^3). A low count can contribute to bleeding and affect the use of epidural anesthesia.
The client in labor received an epidural anesthesia 20 minutes ago. The nurse assesses that the client's BP is 98/62mmHg and that the client is lying supine. What should the nurse do next?
Position the client in a left side-lying position - This displaces the uterus and alleviates aortocaval compression
The nurse admits the client at 34 weeks' gestation for preterm labor as a result of a battledore placenta. The nurse should plan to monitor for which most common complication associated with battledore placenta?
Preterm labor with bleeding - a battledore placenta occurs when the umbilical cord is inserted at or near the placenta margin. It most commonly results in preterm labor and bleeding.
SELECT ALL: the nurse is caring for the pregnant client. Which assessment findings help the nurse determine that she may be in true labor?
Progressive cervical dilation and effacement Walking usually increases contraction intensity Contractions increase in duration and intensity
The laboring client is at 5/100/0, ROA, and having difficulty coping with her contractions. She does not want epidural analgesia or medications. How can the nurse best assist the client and her partner?
Reemphasize modified-paced breathing techniques - breathing techniques provide distraction, reduce pain perception, and help the client maintain control during labor. The modified-paced breathing technique is usually more effective during active labor (4 to 7 cm). The client is at 5 cm. The modified-paced technique is performed at about twice the normal breathing rate and requires that the client remain alert and concentrate fully on her breathing.
The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?
Reposition the client - repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent.
After performing Leopold's maneuvers and determining that the fetus is in the RSA position, the nurse plans to assess the FHR. What area of the client's abdomen would the nurse best be able to listen to and count the FHR?
The RUQ of the client's abdomen is the best area to listen to and count the FHR when the fetus is in the RSA position. When the fetus is in RSA position, the fetal back faces the client's right side. The fetal presentation is breech, and the fetal head is in the upper segment of the client's abdomen. The FHR is heard most clearly through the fetal back. This is designated as the area of maximal intensity or loudness, providing clarity of fetal heart sounds.
The pregnant client presents with regular contractions that she describes as "strong." Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?
The client is experiencing early labor - early labor is a pattern of labor that occurs when contractions become regular and the cervix dilates to 3cm
The primigravida client has been pushing for 2 hours when the infant's head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse's interpretation of this information?
The infant has a shoulder dystocia - the "turtle sign" occurs when the infant's head suddenly retracts back against the mother's perineum after emerging from the vagina, resembling a turtle pulling its head back into its shell. This head retraction is caused by the infant's anterior shoulder being caught on the back of the maternal pubic bone (shoulder dystocia), preventing delivery of the remainder of the infant.
The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/-2, RSP. How should the oncoming shift nurse interpret this documentation?
The nurse should interpret 3/100/-2, RSP as the cervix is 3cm dilated, 100% effaced, and the fetus is 2cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother's pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P).
The laboring client is experiencing dyspnea diaphoresis, tachycardia, and hypotension while lying on her back. Which intervention should the nurse implement immediately?
Turn the client onto her left side - when the laboring client lies flat on her back, the gravid uterus completely occludes the inferior vena cava and laterally displaces the subrenal aorta. This aortocaval compression reduces maternal cardiac output, producing dyspnea, diaphoresis, tachycardia, and hypotension. Other symptoms include air hunger, nausea, and weakness. A left side-lying position decreases aortocaval compression.
the client, whose parity is 1, had a vaginal delivery 6 days ago and arrived home yesterday after treatment of endometritis. the home health nurse visits the client and plans teaching after seeing which most concerning item in the client's bathroom?
a box of tampons of the floor outside the shower stall - the tampon my irritate or dry the vagina, holds lochia in the body, and increases the risk of infection. the client should be instructed to wear a peri-pad
twenty-four hours after the birth of her first child, the 25-year-old single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle which method of birth control should the nurse suggest?
a female condom with nonoxynol-9 - a female condom does provide protection against some of the pathogens that cause STIs, and it would be readily available over the counter
SELECT ALL - the husband of the postpartum client diagnosed with moderate postpartum depression (PPD) asks the nurse about the treatments his wife will require. The nurse's response should be based on knowing that which treatments are included in the initial collaborative plan of care?
antidepressant medication individual or group psychotherapy
SELECT ALL: while assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client's breasts are hard and painful. Which interventions should be implemented by the nurse?
apply ice packs to the breasts at intervals between feedings administer an anti-inflammatory medication prescribed PRN pump the breasts as needed to ensure complete emptying
the client delivered vaginally 6 hours ago, and is upset about bleeding too much. she shows to nurse the peri-pad that was just removed. what should the nurse do first?
ask her how long she has been wearing this pad - while a constant trickle or oozing of lochia would indicate excessive bleeding, the nurse would need to first know how long the client had been wearing the peri-pad to evaluate whether the amount was excessive. the client should not be saturating a large peri-pad every hour. if the client had been wearing the same pad for 3 or 4 hours, it may indicate an expected amount of lochia.
the postpartum client delivered a healthy newborn 36 hours previously. the nurse finds the client crying and asks what is wrong. the client replies "nothing, really. I'm not in pain or anything, but i just seem to cry a lot for no reason." what should be the nurse's first intervention?
ask the client to discuss her birth experience - a key feature of postpartum blues is episodic tearfulness without an identifiable reason. interventions for postpartum blues include allowing the client to relive her birth experience
The postpartum client delivered a full-term infant 2 days previously. The client states to the nurse, "My breasts seem to be growing, and my bra no longer fits." Which statement should be the basis for the nurse's response to the client's concern?
breast tissue increases in the early postpartum period as milk forms - a bra that was adequate during pregnancy may no longer be adequate by the second or third postpartum day
ORDER OF ACTION: The pregnant client has been pushing for 2.5 hours. After some difficulty, the large fetal head emerges. The HCP attempts to deliver the shoulders without success. Place the nurse's actions in caring for the client in the correct sequence.
call for neonatal resuscitation team to be present place the client in exaggerated lithotomy position apply suprapubic pressure per direction of the HCP catheterize the client's bladder prepare for emergency cesarean birth
The client, who delivered a 4200g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client's fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?
call the client's HCP and request an additional visual examination - the nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair
the client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. an oral analgesic was given and ice applied to the perineum earlier. what should the nurse do now?
closely reinspect the perineum - a forceps-assisted delivery can increase the risk of hematoma development. rectal pressure and perineal pain can indicate a hematoma in the posterior vaginal wall. the nurse should closely examine the perineum and the vaginal introitus for ecchymosis and a bulging mass
The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?
completely dilated and 100% effaced - systemic medications such as nalbuphine hydrochloride (Nubain), should not be administered when advanced dilation is present (transition stage of labor) because its use can lead to respiratory depression if given too close to the time of delivery.
Twenty-four hours post-vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement since before delivery. Which actions should be taken by the nurse?
document the data in the client's medical record - a spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea and decreased food intake and dehydration during labor. Thus documentation of the lack of a BM is the only action required.
Immediately after delivery of the client's placenta, the nurse palpates the client's uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which actions should the nurse take based on the assessment findings?
document the findings of the fundus - immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment finding.
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results? HCT - 35% Hgb - 11g/dL WBCs - 20,000/mm^2
document the laboratory report findings - all value are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum periods because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. HCT and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution
The RN and the student nurse are caring for the postpartum client who is 16 hours postdelivery. The RN evaluates that the student needs more education about uterine assessment when the student is observed doing which activity?
elevating the client's head 30 degrees before doing the assessment - for the uterine assessment, the client should be positioned in a supine position so the height of the uterus is not influenced by an elevated position.
the nurse observes the postpartum multiparous client rubbing her abdomen. When asked if she is having pain, the client says, "it feels like menstrual cramps." Which intervention should the nurse implement?
encourage her to lie on her stomach until the cramps stop - multiparous women frequently experience intermittent uterine contractions called afterpains. Lying in a prone position applies pressure to the uterus, stimulating continuous uterine contraction. When the uterus maintains a state of contraction, the afterpains will cease.
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client's leg. Which action by the nurse in response to the client's bleeding is correct?
explain that extra bleeding can occur with initial standing - lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knowns the fundus is firm and not bleeding, a simple explanation to the client is all that is required.
The client has a vaginal delivery of a full-term newborn. Immediately after delivery, the nurse assesses that the client's perineum and labia are edematous, but she does not have an episiotomy or perineal laceration. Which intervention should the nurse implement?
give her an ice pack to apply to the perineum - if perineal edema is present, an ice pack should be applied for the first 24 hours. ice reduces edema and vulvar irritation
SELECT ALL: the postpartum client suffered a fourth degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the client's plan of care?
instruct the client on a high fiber diet give prn prescribed stool softeners in the am and at hs
Before hospitalization, an adolescent client had decided to give up her newborn for adoption. The client had an uncomplicated vaginal delivery and is still committed to her decision. Which intervention should the nurse exclude?
notify her family to ensure that support is available upon her discharge - the adolescent may not have disclosed the pregnancy to family. Although it would be appropriate for the nurse to explore the client's support system with the client, the nurse should not contact the client's family.
The nurse is caring for the 30-weeks-pregnant client who is having contractions every 1.5 to 2 minutes with spontaneous rupture of membranes 2 hours ago. Her cervix is 8 cm dilated and 100% effaced. Delivery is imminent. What intervention is most important now?
notify neonatology for the impending birth - the team members will be needed for respiratory support and possible resuscitation
The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60 to 70 seconds. The client states extreme pain in the small of her back. Her abdomen revels a small depression under the umbilicus. Which fetal position should the nurse document?
occiput posterior - characterized by intense back pain (back labor). A depression under the umbilicus occurs as a result of the posterior shoulder.
SELECT ALL: the nurse is caring for the client who is 28 hours postpartum. which assessment findings should prompt the nurse to notify the HCP of possible puerperal infection?
oral temperature of 102.2F (39C) lochia discharge that is foul smelling
in the process of preparing the client for discharge after a c-section, the nurse addresses all of the following areas during discharge education. Which should be the priority advice for the client?
planning for assistance at home - because the client has had a surgical procedure, the priority consideration is for the mother to plan for additional assistance at home. Without this assistance, it is difficult for the mother to get the rest she needs for healing, pain control. and appropriate infant care.
The nurse is about to auscultate the FHR on the client in triage. What information should be determined first to find the correct placement for auscultation?
position of the fetus - The nurse should first perform Leopold's maneuvers to determine the fetal position. This will enable proper placement of the Doppler device over the location of the FHR.
ORDER OF ACTION: The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client's uterine fundus. Prioritize the nurse's actions to locate the client's fundus by placing each step in the correct sequence.
position the client supine place the side of one hand just above the client's symphysis pubis place the other hand at the level of the umbilicus press deeply into the abdomen massage the abdomen in a circular motion if the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage
SELECT ALL: the nurse is evaluating the 39-weeks-pregnant client who reports greenish, foul smelling vaginal discharge. Her temperature is 101.6F (38.7C), and the FHR is 120 with minimal variability and no accelerations. The client's group beta streptococcus (GBS) culture is positive. Which interventions should the nurse plan to implement?
prepare for cesarean birth due to chorioamnionitis start ATBs as directions for the GBS infection prepare the client for epidural anesthesia notify the neonatologist of the client's status
The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should the nurse do first?
put continuous pressure on the presenting part to keep it off the cord - prevents further cord compression. This is continued until birth, which is usually by cesarean birth.
SELECT ALL: the nurse is caring for the postpartum primiparous client who is 13 hours post-vaginal delivery. The nurse observes that the client is passive and hesitant about making decisions about her own and her newborn's care. In response to this observation, which interventions should be implemented by the nurse?
question her closely about the presence of pain ask if she would like to talk about her birth experience encourage her to nap when her infant is napping
SELECT ALL: the postpartum client is being admitted for mastitis. The nurse should prepare the client for which interventions?
receiving a prescribed oral antibiotic applying a warm packs to the breasts getting prescribed anti-inflammatory drug emptying the milk from her breasts frequently
At one minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the APGAR score, what should the nurse do next?
recheck the APGAR score at 5 minutes after birth - this will determine if the newborn is continuing to make a good transition to the extrauterine environment
When looking in the mirror at her abdomen, the postpartum client says to the nurse, "My stomach still looks like I'm pregnant!" The nurse explains that the abdominal muscles, which separate during pregnancy, will undergo which change?
regain prepregnancy tone with exercise -the "I'm still pregnant" appearance is caused by relaxation of the abdominal wall muscles. With exercise, most women can regain prepregnancy abdominal muscle tone within about 6 weeks.
The nurse is caring for the client who just gave birth. Which observation should lead the nurse to be concerned about the client's attachment to her male infant?
repeatedly telling her husband that she wanted a girl - attachment is demonstrated by expressing satisfaction with a baby's appearance and sex. frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up.
The nurse is caring for the postpartum family. The nurse determines that paternal engrossment is occurring when which observation is made of the newborn's father?
shows similarities between his and the baby's ears - engrossment is demonstrated by the father touching the infant, making eye contact with the infant, and verbalizing awareness of features in the newborn that are similar to his and that validate his claim to that newborn
Two hours after the client's vaginal delivery, she reports feeling "several large, warm gushes of fluid" from her vagina. The nurse assesses the client's perineum and finds a large pool of blood on the client's bed. Which nursing action is priority?
support the lower uterine segment with one hand and assess the fundus with the other - increased bleeding will occur if soft or "boggy". Failing to support the lower uterine segment may result in inversion of the uterus
The delivery nurse is reporting to the postpartum nurse about the client who just delivered her first baby, a term newborn. Which number should the delivery nurse report for the client's parity?
the client has given birth to her first child - her parity is 1
the nurse is caring for four postpartum clients. which client should be the nurse's priority for monitoring uterine atony?
the client who delivered a macrosomic baby after a 12 hour labor - a macrosomic baby stretches the client's uterus, and this the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively
ORDER OF ACTION: the nurse receives report for four postpartum clients. in which order should the nurse assess the clients? prioritize the clients in order from first to last.
the client who had a normal, spontaneous vaginal delivery 30 minutes ago the client who delivered her newborn via scheduled c-section 8 hours ago and has a PCA pump with morphine for pain control the client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding the client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant
after delivering a full-term infant, the breastfeeding mother asks the nurse if there is any contraceptive method that she should avoid while she is breastfeeding. Which contraceptive should the nurse advise the client to avoid?
the combined oral contraceptive (COC) pill - birth control pills containing progesterone and estrogen (COC) can cause a decrease in milk volume and may affect the quality of the breast milk
SELECT ALL: the student nurse reports to an experienced nurse finding a warm, red, tender area on the left calf of the client who is 48 hours post-vaginal delivery. the nurse assesses the client and explains that postpartum clients are at increased risk for thrombophlebitis due to which factors?
the fibrinogen levels in the blood of postpartum clients are elevated pressure is placed on the legs when elevated in stirrups during delivery dilation of veins in the lower extremities occurs during pregnancy compression in the common iliac vein occurs during pregnancy
SELECT ALL: the nurse is evaluating a breastfeeding session. The nurse determines that the infant has appropriately latched on to the mother's breast when which observations are made?
the mother reports a film tugging feeling on her nipple the baby's nose, mouth and chin are touching the breast the infant's cheeks are rounded when sucking the infant's swallowing can be heard after sucking
The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus's long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse's documentation of the lie of the fetus?
transverse - a transverse lie occurs in 1 in 300 births and is marked by the fetus's lying in a side-lying position across the abdomen
SELECT ALL: The nurse reviews information and assesses the laboring client at 42 weeks' gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction?
umbilical cord prolapse transverse fetal lie previous cesarean incision
The postpartum client, who is 24 hours post-cesarean section, tells the nurse that she has much less lochial discharge after this birth than with her vaginal birth 2 years ago. The client asks if this is normal after a cesarean birth. Which statement should be the basis for the nurse's response?
women normally have less lochial discharge after a cesarean birth - the uterus is cleaned during surgery
the client is diagnosed with moderate PPD after vaginal delivery of a 10lb baby. one week following the delivery, the nurse completes a home visit. which finding is the priority?
yells at her baby to stop crying - it is inappropriate for the client to yell at her baby to stop crying. verbal abuse can escalate to physical abuse. the safety of the infant should be the nurse's priority.
