3871 prepU quiz Reproduction
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: -1 to 2. -5 to 9. -7 to 10. -12 to 15.
-7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.
A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take? -Ask the client to get out of bed and try to urinate. -Call the physician for a methylergonovine order. -Assess the fundus and massage it if it's boggy. -Give the client a new pad and check her in 30 minutes.
-Assess the fundus and massage it if it's boggy. The nurse should first asses the fundus to determine if clots are present or if uterine involution has occurred. Clots, no uterine involution, and the saturation of two perineal pads within 30 minutes could indicate postpartum hemorrhage. If the fundus is boggy, massaging it will suppress bleeding by encouraging the uterus to contract upon itself and the open vessels that were attached to the placenta. Massaging also helps to expel clots or tissue remaining from the birth. If the nurse assesses a firm fundus, she should next assess for a full bladder and then ask the client to try to urinate. If the uterus remains boggy after massage, the nurse should obtain an order from the physician for methylergonovine. Waiting 30 minutes without intervening could contribute to uterine hemorrhage.
The infant has Apgar scores of 7 at 1 minute and 9 at 5 minutes. What is the indication of this assessment finding? -severe distress and absolute need of resuscitation -adjusting to extrauterine life -moderate difficulty and may need intervention -predicts fair neurologic future outcomes
-adjusting to extrauterine life The infant is tolerating the adjustment to extrauterine life; the APGAR scores are within normal limits for appropriate transition. Severe distress and absolute need for resuscitation is an APGAR score of 0 to 3; moderate difficulty is indicated by a score of 4 to 7. An APGAR of 8 to 10 at 5 minutes indicates a fair neurologic future outcome.
A nurse is monitoring the FHR of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention should the nurse implement? -Encourage the Valsalva maneuver. -Change maternal position to an upright or side lying position. -Administer exogenous oxytocin. -Place the client in the lithotomy position.
-Change maternal position to an upright or side lying position. To intervene with late decelerations, the nurse should change maternal position to an upright or side lying posture. Late deceleration in the fetus indicates insufficient uteroplacental perfusion. Changing the maternal position improves the maternal venous return. In upright position, the uterine activity becomes more efficient. Attempts should be made to increase the uteroplacental perfusion and fetal circulation. Administering oxytocin and encouraging Valsalva maneuver (extended breath holding) may augment the uteroplacental insufficiency. In late deceleration, the nurse should administer oxygen through nasal cannula and discontinue administration of oxytocin. Placing the client in the lithotomy position contributes to poor placental circulation.
During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first? -Gently massage the fundus. -Assess the client for infection. -Determine if the uterus has ruptured. -Increase the intravenous fluid rate.
-Gently massage the fundus. Uterine atony means that the uterus is not firm because it is not contracting. First, the nurse should gently massage the uterus in an effort to help contract the uterus and make it firm. Clients with multiple gestation, polyhydramnios, prolonged labor, or large-for-gestational-age fetus are more prone to uterine atony. Assessing for infection is inappropriate because puerperal infection is not associated with uterine atony. Determining if the uterus has ruptured is inappropriate because uterine atony is not a sign of uterine rupture. Increasing the intravenous fluid rate may be prescribed if the client develops symptoms of shock.
A first-time mother is nervous about breastfeeding. Which intervention would the nurse perform to reduce maternal anxiety about breastfeeding? -Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience. -Explain that breastfeeding comes naturally to all mothers. -Tell her that breastfeeding is a mechanical procedure that involves burping once in a while and that she should try finishing it quickly. -Ensure that the mother breastfeeds the newborn using the cradle method.
-Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience. The nurse should reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience; this information will help to reduce the feelings of frustration and uncertainty about their ability to breastfeed. The nurse should also explain that breastfeeding is a learned skill for both parties. It would not be correct to say that breastfeeding is a mechanical procedure. In fact, the nurse should encourage the mother to cuddle and caress the newborn while feeding. The nurse should allow sufficient time to the mother and child to enjoy each other in an unhurried atmosphere. The nurse should teach the mother to burp the newborn frequently. Different positions, such as cradle and football holds and side-lying positions, should be shown to the mother.
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.
A nurse who is caring for newborn infants delivers care by utilizing the sense that is most highly developed at birth. Which example of nursing care achieves this goal? -The nurse speaks to the infant in a loud voice to get attention. -The nurse plays "peek-a-boo" with the infant. -The nurse wears colorful clothing to stimulate the infant. -The nurse gently strokes the baby's cheek to facilitate breastfeeding.
-The nurse gently strokes the baby's cheek to facilitate breastfeeding. The sense most highly developed at birth would be the sense of neurological reflex. The nurse gently stroking the baby's cheek to have the baby turn toward the stroke is a developmental reflex. The nurse would not use a loud voice or wear colorful clothing while caring for a newborn. The infant is not at the stage of development where playing "peek-a-boo" would be appropriate.
A nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care? -Using a peri bottle to clean the perineum after each voiding or bowel movement -Cleaning the perineum from back to front after a bowel movement -Spraying water from peri bottle into the vagina -Changing perineal pads every 8 hours
-Using a peri bottle to clean the perineum after each voiding or bowel movement Cleaning with a peri bottle (squirt or spray bottle) should be performed after each voiding or bowel movement. The perineum should be cleaned from front to back, to avoid contamination from the rectal area. To keep the perineum clean, perineal pads must be changed when they are soiled. Water from the peri bottle isn't sterile and should never be directed into the vagina.
A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client? -Actively stimulate the infant to cry. -Offer blow-by oxygen. -Wrap the infant in a blanket and hand to the mother for bonding. -Place the infant in a warmer bed and heat the newborn up.
-Wrap the infant in a blanket and hand to the mother for bonding. Apgar scores of 7-10 at 5 minutes of age indicate a newborn is adapting well to extrauterine life and can be safely placed with the mother. A 5-minute Apgar score of 4-6 would mean that the newborn might have respiratory distress and need oxygen or requires more vigorous stimulation. Hypothermia can also cause distress and lower the Apgar score.
When performing Leopold's maneuvers, which action would the nurse ask the client to perform to ensure optimal comfort and accuracy? -breathe deeply for 1 minute -empty her bladder -drink a full glass of water -lie on her left side
-empty her bladder Leopold's maneuvers involve abdominal palpation. The client should empty her bladder before the nurse palpates the abdomen. Doing so increases the client's comfort and makes palpation more accurate. Although breathing deeply may help to relax the client, it has no effect on the accuracy of the results of Leopold's maneuvers. The client does not need to drink a full glass of water before the examination. The client should be lying in a supine position with the head slightly elevated for greater comfort and with the knees drawn up slightly.
A 36-year-old primigravid client at 22 weeks' gestation without any complications to date is being seen in the clinic for a routine visit. The nurse should assess the client's fundal height to: -determine the level of uterine activity. -identify the need for increased weight gain. -assess the fetal position. -estimate the fetal growth.
-estimate the fetal growth. Assessment of fundal height is a gross estimate of fetal growth. By 20 weeks' gestation, the height of the fundus should be at the level of the umbilicus, after which it should increase 1 cm for each week of gestation until approximately 36 weeks' gestation. Fundal height that is significantly different from that implied by the estimated gestational age warrants further evaluation (e.g., ultrasound examination) because it possibly indicates multiple pregnancy or fetal growth retardation. Fundal height estimation will not determine uterine activity or a need for increased weight gain. Leopold's maneuver will determine fetal position, but is not typically done in the second trimester when the fetus is still freely moving.
A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by: -flatulence accumulation after a cesarean birth. -healing of the abdominal incision after cesarean birth. -adverse effects of the medications administered after birth. -release of oxytocin during the breastfeeding session.
-release of oxytocin during the breastfeeding session. Breastfeeding stimulates oxytocin secretion, which causes the uterine muscles to contract. These contractions account for the discomfort associated with afterpains. Flatulence may occur after a cesarean birth. However, the mother typically would have abdominal distention and a bloating feeling, not a "cramplike" feeling. Stretching of the tissues or healing may cause slight tenderness or itching, not cramping feelings of discomfort. Medications such as mild analgesics or stool softeners, commonly administered postpartum, typically do not cause cramping.
When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" -saturating 1 pad in 3 hours -saturating 1 pad in 1 hour -saturating 1 pad in 6 hours -saturating 1 pad in 8 hours
-saturating 1 pad in 1 hour Bleeding is considered heavy when a woman saturates a sanitary pad in 1 hour. Excessive bleeding occurs when a postpartum client saturates 1 pad in 15 minutes. Moderate bleeding occurs when the bleeding saturates less than 15 cm of a pad in 1 hour.
A baby has just been delivered. Her heart rate at one minute of age in 130 beats per minute and she is crying vigorously. Her extremities are flexed and she withdraws her feet when the soles are touched. Her trunk is pink and hands and feet are bluish. Based on the findings, which of the following should the nurse record as the baby's Apgar score? -10 -9 -8 -7
9 Heart rate of 130 bpm = 2 points, vigorous cry = 2 points, muscle tone = 2 points, flexed position = 2 points, acrocyanosis = 1 point, Apgar score = 9 points.
The LPN has reported that uterine massage is ineffective on a client. The nurse anticipates the health care provider will prescribe which medication to address this issue? -Ibuprofen -Oxytocin -Penicillin -Digoxin
Oxytocin Oxytocin is the drug used first for uterine atony. Other medications which may be ordered include ergonovine, methylergonovine, carboprost, and misoprostol. Ibuprofen, penicillin, or digoxin would have no effect on uterine atony.
