444: Exam 3 - Davis Success & Lecture notes

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Nursing interventions if pt c/o heavy bleedig

-ask the last time the pad was changed -CHECK THE FUNDUS for firmness -if not firm (foggy, mushy): bleeding risk (vasodilating) -should be as firm (mini basketball) -massage the fundus to stimulate contraction -Give LR -Give methergine to immediately start the bleeding -check if bladders are full (pushes the uterus to the side)

Causes of uterine atony

-overdistended uterus: macrosomic baby, polyhydramnios -multiparity -precipitate or prolonged labor: fast or slow labor -forceps or vacuum -manual removal -uterine inversion -placenta previa -general anesthesia -emergency c section -chorioamnionitis -infection in the amniotic fluid -clotting disorders -Magnesium sulfate

Pt education: Episiotomy (perineum care)

-perineal bottle (w/ warm water) -Sitz bath (order by Dr) -topical anesthetics spray (cold numbing): dermaplants -witch hazel on rectal area -percocet (Q4h: Tylenol +narcotic) + ibuprofen. Ok to give together

A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.

A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse's response? 1. The client's obstetric status is optimal for receiving the vaccine. 2. The client's immune system is highly responsive during the postpartum period. 3. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. 4. The client's insurance company will pay for the shot if it is given during the immediate postpartum period.

A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? 1. Respiratory rate 8 rpm. 2. Complaint of thirst. 3. Urinary output of 250 mL/hr. 4. Numbness of feet and ankles.

REEDA

Redness Edema Ecchymosis Discharge Approximated (skin should be together)

A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Demerol (meperidine). 3. Seconal (secobarbital). 4. Benadryl (diphenhydramine).

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The woman should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The woman must have her vitals assessed every two days.

Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order? 1. Postpartum clients are at high risk for thrombus formation. 2. Post-cesarean clients are at high risk for fluid volume deficit. 3. Postpartum clients are at high risk for varicose vein development. 4. Post-cesarean clients are at high risk for footdrop.

Which of the following nursing interventions would be appropriate for the nurse to perform to achieve this client care goal: The client will not develop postpartum thrombophlebitis? 1. Encourage early ambulation. 2. Promote oral fluid intake. 3. Massage the legs of the client twice daily. 4. Provide the client with high-fiber foods.

The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

1 TEST-TAKING TIP: A second-degree laceration affects the skin, vaginal mucosa, and underlying muscles. (It does not affect the rectum or rectal sphincter.) Because of the injury, the area often swells, causing pain. Ice packs help to reduce the inflammatory response and numb the area.

A nurse is performing a postpartum assessment on a client who delivered by cesarean section. Which of the following actions will the nurse perform? Select all that apply. 1. Auscultate the abdomen. 2. Palpate the fundus. 3. Assess the nipple integrity. 4. Assess the central venous pressure. 5. Auscultate the lung fields.

1 2 3 5 TEST-TAKING TIP: Cesarean clients are surgical clients as well as postpartum clients. They should be monitored for complications associated with major abdominal surgery, for example, paralytic ileus and pneumonia. They should also be monitored for complications associated with labor, delivery, and the postpartum, for example, boggy uterus and cracked nipples. Some are reticent to palpate the fundus because of the pain it causes, but if the fundus does not contract effectively, the client is at high risk for hemorrhage—a very serious postpartum complication.

During a postpartum assessment, it is noted that a G1 P1001 woman who delivered vaginally over an intact perineum has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure.

1 2 5 1. Sitz baths do have a soothing affect for clients with hemorrhoids. 2. Clients often feel some relief when external hemorrhoids are reinserted into the rectum. 5. Topical anesthetics can provide relief from the discomfort of hemorrhoids.

A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine? 1. The woman should not become pregnant for at least 4 weeks. 2. The woman should pump and dump her breast milk for 1 week. 3. Surgical masks must be worn by the mother when she holds the baby. 4. Antibodies transported through the breast milk will protect the baby.

1 This statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if the woman becomes pregnant within 4 weeks of receiving the injection.

2 main postpartum assessments

1) Fundus firmness 2) urinary output

Puerperal phases: Taking in

1-2 days -in shock, out of touch with reality -focus is on mom

A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

1. TEST-TAKING TIP: The uterus of a woman who delivers a macrosomic baby has been stretched beyond the usual pregnancy size. The muscle fibers of the myometrium, therefore, are stretched. After delivery the muscles are often unable to contract effectively to stop the bleeding at the placental separation site.

A postoperative cesarean client who was diagnosed with severe pre-eclampsia in labor and delivery is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question? 1. Methergine (methylergonovine). 2. Magnesium sulfate. 3. Advil (ibuprofen). 4. Morphine sulfate.

1. TEST-TAKING TIP: Methergine is an oxytocic agent. It acts directly on the myofibrils of the uterus. Secondarily, it also contracts the muscles of the vascular tree. As a result, clients' blood pressure tends to elevate when they receive this medication. Methergine should not be administered to a client whose blood pressure is 130/90 or higher.

Which of the following is the priority nursing action during the immediate postpartum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

1. Fundal assessment is the priority nursing action. TEST-TAKING TIP: Hemorrhage is one of the primary causes of morbidity and mortality in postpartum women. It is essential, therefore, that nurses repeatedly assess a client's postpartum uterine contraction. When the uterus is well contracted, a woman is unlikely to bleed heavily after delivery.

Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink ice tea with lemon or lime.

1. Lying prone on a pillow helps to relieve some women's afterbirth pains.

A postpartum nurse is caring for a client who received epidural anesthesia during her labor and delivery. The nurse should advise the woman that she may experience which of the following side effects of the medication during the postpartum period? 1. Backache. 2. Light-headedness. 3. Hypertension. 4. Footdrop.

1. Many clients who have received epidurals during labor complain of a backache during the postpartum period.

A client is on magnesium sulfate via IV pump for severe pre-eclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity. TEST-TAKING TIP: The only accurate way to assess for magnesium toxicity is to do a serum magnesium level. Normal magnesium levels are 1.8 to 3 mg/dL. Therapeutic levels are 4 to 8 mg/dL. Reflex depression begins to appear when the levels reach 8 to 12 mg/dL. When levels rise to 15 mg/dL or higher, respiratory depression and, eventually, cardiac arrest occur. Hourly grip strengths performed with reflex assessments are excellent noninvasive assessments to monitor for neuromuscular blockage. If changes are noted, the nurse can notify the healthcare provider, who can order a stat magnesium level.

A client has been transferred to the post-anesthesia care unit from a cesarean delivery. The client had spinal anesthesia for the surgery. Which of the following interventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.

1. This answer is correct. The nurse should assess the level of anesthesia every 15 minutes while in the post-anesthesia care unit.

A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority? 1. Ineffective breastfeeding. 2. Infection. 3. Ineffective individual coping. 4. Pain.

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

The nurse informs a postpartum woman that which of the following is the reason ibuprofen (Advil) is especially effective for afterbirth pains? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen can be administered in high doses.

The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.

Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit, 39%. 2. White blood cell count, 16,000 cells/mm . 3. Red blood cell count, 5 million cells/mm . 4. Hemoglobin, 15 grams/dL.

The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

2 TEST-TAKING TIP: During pregnancy, the bladder loses its muscle tone because of the pressure exerted on it by the gravid uterus. As a result, after delivery mothers often fail to feel when their bladders become distended.

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2 TEST-TAKING TIP: The best tool to use when assessing any incision is the REEDA scale. The nurse assesses for: R—redness, E—edema, E—ecchymosis, D—drainage, and A—poor approximation. If there is evidence of any of the findings, they should be documented, monitored, and reported.

A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2 TEST-TAKING TIP: This client's gravidity and parity indicate that she is a grand multipara. She has been pregnant 10 times, carrying 6 babies to term and 4 babies preterm. Because her uterus has been stretched so many times, she is at high risk for uterine atony during the postpartum period. The nurse must, therefore, monitor the postpartum contraction of her uterus very carefully.

A client, G1 P0101, postpartum 1 day is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary healthcare provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

2 TEST-TAKING TIP: When a postpartum client's bladder is distended, the uterus becomes displaced and boggy. The client should be escorted to the bathroom to void; the lochia flow should also be assessed. However, before escorting the client to urinate, the nurse should gently massage the uterus.

One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell (WBC) count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.

2 3 4 TEST-TAKING TIP: The WBC is elevated during late pregnancy, delivery, and early postpartum, but if it rises very rapidly, the rise is often associated with a bacterial infection. The lochia usually smells "musty." When a client has endometritis, however, the lochia smells "foul." A temperature above 100.4°F/38°C after the first 24 hours postpartum is indicative of a puerperal infection.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. 1. The woman performs the procedure twice a day. 2. The woman washes her hands before and after the procedure. 3. The woman sits in warm tap water for ten minutes three times a day. 4. The woman sprays her perineum from front to back. 5. The woman mixes warm tap water with hydrogen peroxide.

2 4 TEST-TAKING TIP: A postpartum client is taught to spray warm tap water with nothing added on the perineum, from front to back, after each toileting and whenever she changes her peripads. She should also be taught to wash her hands before and after the procedure.

A post-cesarean section, breastfeeding client whose subjective pain level is 2/5 requests her as-needed (prn) narcotic analgesics every 3 hours. She states, "I have decided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? 1. The woman needs a stronger narcotic order. 2. The woman is high risk for severe constipation. 3. The woman's breast milk volume may drop while taking the medicine. 4. The woman's newborn may become addicted to the medication.

2 This statement is correct. One of the common side effects of narcotics is constipation. TEST-TAKING TIP: Because clients who take narcotics are at high risk for constipation, the nurse should inform clients of the potential and advise them to take necessary precautions. For example, the clients should be advised to drink fluids, eat high-fiber foods, and ambulate regularly.

The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby-care skills such as diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills such as pumping.

2. During the taking in phase, clients need to internalize their labor experiences. Discussing the labor process is appropriate for this postpartum phase.

A mother, G1 P1, who delivered a 2,800 gram baby vaginally 30 minutes earlier, is transferred to the postpartum unit. She pushed for 45 minutes and the placenta was delivered 10 minutes later. She is receiving an intravenous with 20 units oxytocin added. The postpartum nurse questions why the oxytocin was added to the IV bag. Which of the following responses by the transferring nurse is most likely? "The medication was added 10 minutes ago to prevent excess bleeding during her transfer." "The medication was added immediately after the baby's birth to promote placental delivery." "The medication was added after the placenta was delivered because of its rapid separation." "The medication was added while she was pushing to speed up the baby's birth."

2. It is likely that the medication was added during the 3rd stage of labor to promote placental delivery. TEST-TAKING TIP: Postpartum hemorrhage (PPH) is a leading cause of maternal death. One effective means of preventing PPH is active management of the 3rd stage of labor. In other words, oxytocin is administered after the birth of the baby to promote uterine contraction and placental delivery. The oxytocin is usually added to the client's IV infusion and the infusion is continued until the fluid is fully absorbed.

The surgeon has removed the surgical cesarean section dressing from a postop day 1 client. Which of the following actions by the nurse is appropriate? 1. Irrigate the incision twice daily. 2. Monitor the incision for drainage. 3. Apply steri strips to the incision line. 4. Palpate the incision and assess for pain.

2. This is appropriate. The nurse should assess for all signs on the REEDA scale. TEST-TAKING TIP: Once the dressing has been removed, the nurse on each shift should monitor the incision line for all signs on the REEDA scale—redness, edema, ecchymosis, discharge, and approximation.

A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following? 1. Weight of the uterine body is significantly reduced. 2. Excess blood volume from pregnancy is circulating in the woman's periphery. 3. Cervix is fully dilated and the lochia flows freely. 4. Maternal blood pressure drops precipitously once the baby's head emerges.

2. This response is true. Once the placenta is birthed, the reservoir for the mother's large blood volume is gone. TEST-TAKING TIP: It is essential that the nurse closely monitor the vital signs of a newly delivered gravida. Because of the surge in blood volume resulting from the delivery of the placenta, the woman is at high risk for cardiovascular compromise. Women frequently develop bradycardia, a normal finding, as a result of the increased peripheral blood volume.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terrible. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Post-trauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.

A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Notify the neonate's pediatrician.

3 TEST-TAKING TIP: Because the client's blood volume is returning to its nonpregnant level, the client loses fluids via both the kidneys and through insensible loss. As a result, postpartum women often awake from sleep with their nightwear saturated with perspiration.

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3 TEST-TAKING TIP: During pregnancy, the blood volume increases by almost 50%. Once the placenta is delivered, the client no longer needs the added blood volume. Immediately after delivery, therefore, the woman experiences marked diuresis and diaphoresis as the blood volume drops.

The nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

3 TEST-TAKING TIP: Lochia rubra is bright red, lochia serosa is pinkish to brownish, and lochia alba is whitish. The nurse would expect the fundus to descend below the umbilicus approximately 1 cm per postpartum day. In other words, 1 day postpartum, the fundus is usually felt 1 cm below the umbilicus; 2 days postpartum, it is usually felt 2 cm below the umbilicus, and so on.

The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary healthcare provider? 1. White blood cells, 12,500 cells/mm . 2. Red blood cells, 4,500,000 cells/mm . 3. Hematocrit, 26%. 4. Hemoglobin, 11 g/dL

3 The client's hematocrit is well below normal. This value should be reported to the client's healthcare provider. The hematocrit of a postpartum woman is likely to be below the "normal" of 35% to 45%, but a hematocrit of 30% or lower is considered abnormal and should be reported to the client's healthcare provider. It is likely that the client will be prescribed iron supplements.

Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration in comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

3. TEST-TAKING TIP: It is likely that most clients will have multiple nursing diagnoses. The nurse must then determine which is (are) the priority diagnosis(ses). It is essential that the nurse remember Maslow's hierarchy of needs. Although psychosocial needs are very important, the physiological needs, especially those related to the respiratory and the cardiovascular systems, must take precedence.

A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

3. Cramping is an expected outcome of the administration of Methergine. TEST-TAKING TIP: Methergine is administered to postpartum clients to stimulate their uterus to contract. As a consequence, clients frequently complain of cramping after taking the medication. The nurse can administer the prn pain medication to the client at the same time the Methergine is administered to help to mitigate the client's discomfort.

A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate the baby's positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

3. Rotating positions at feedings is one action that can help to minimize the severity of sore nipples. TEST-TAKING TIP: If a mother rotates positions at each breastfeeding, the baby is likely to put pressure on varying points on the nipple. A good, deep latch, however, is the most important way to prevent nipple soreness and cracking. The mother could also apply lanolin to her breasts after each feeding.

A medication order reads: Methergine (ergonovine) 0.2 mg PO q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3. The blood pressure should be assessed before administering Methergine. TEST-TAKING TIP: Methergine is an oxytoxic agent that works directly on the myofibrils of the uterus. The smooth muscle of the vascular tree is also affected. The blood pressure may elevate, therefore, to dangerous levels. The medication should be held if the blood pressure is 130/90 or higher and the woman's healthcare practitioner should be notified if appropriate.

A client, G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

3. This action is very important. If the legs are removed from the stirrups one at a time, then the woman is at high risk for back and abdominal injuries.

The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on the third postpartum day. 2. Administer analgesics every four hours per doctor's orders. 3. Teach the client to contract her buttocks before sitting. 4. Irrigate the incision twice daily with antibiotic solution.

3. This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the suture line. TEST-TAKING TIP: Clients who have had episiotomies often avoid sitting normally. Nurses should encourage them to take medications as needed, to contract their buttocks before sitting, and to sit normally rather than trying to favor one buttock over the other. Mediolateral incisions, incisions that are cut at approximately a 45-degree angle from the perineum, tend to be more painful than midline incisions—incisions cut posteriorly from the vagina toward the rectum.

A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3,000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

A bottle-feeding woman, 11⁄2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated two pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

A nurse massages the uterus of a postpartum woman after diagnosing the woman at risk for injury related to uterine atony. Which of the following outcomes would indicate that the client's condition had improved? 1. Heavy lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus firm at the umbilicus.

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

4 TEST-TAKING TIP: Because they have elevated clotting factors, postpartum clients are at high risk for thrombus formation. When they need to urinate, they should be encouraged to ambulate to the bathroom to prevent pooling of blood in the dependent blood vessels. Clients should be accompanied to the bathroom during the early postpartum period, however, because they may be light- headed from the stress and work of labor and delivery.

A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority? 1. Lochia is serosa. 2. Client cries throughout the visit. 3. Nipples are cracked. 4. Client yells at the baby for crying.

4 TEST-TAKING TIP: The baby is the most vulnerable member of the mother-infant dyad. Because the baby is completely dependent on the care of the mother, if the nurse discovers any behavior or other evidence that makes him or her suspicious of child abuse or neglect, the nurse is obligated both morally and legally to report the situation. Clients who are experiencing postpartum depression usually perform baby care competently.

A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.

4 5 TEST-TAKING TIP: The postpartum body naturally prepares to breastfeed a baby. To suppress the milk production, the mother should refrain from stimulating her breasts. Both massage and heat stimulate the breasts to produce milk. Mothers, therefore, should be encouraged to refrain from touching their breasts and when showering to direct the warm water toward their backs rather than toward their breasts. A supportive bra will help to minimize any engorgement that the client may experience.

The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother.

4 Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby.

A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

4 It is likely that this client is dehydrated. She should be advised to drink fluids. TEST-TAKING TIP: In the early postpartum period, up to 24 hours after delivery, the most common reason for clients to have slight temperature elevations is dehydration. During labor, clients work very hard, often utilizing breathing techniques as a form of pain control. As a result, the clients lose fluids through insensible loss via the respiratory system.

The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1 P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6°F, 82, 18; fundus firm at umbilicus; moderate lochia rubra; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience.

4 This is the best response. A right mediolateral episiotomy is angled away from the perineum and rectum. TEST-TAKING TIP: This is a difficult analysis level question. The test taker must determine, based on the facts given, which nursing diagnosis is appropriate. This question, however, should be approached the same way that all other questions are approached: (1) determine what is being asked; (2) develop possible answers to the question BEFORE reading the given responses; (3) read the responses and compare them with the list of possible answers; and (4) choose the one response that best compares with the list of possible answers.

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottle feed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4. The nurse should discuss the action of oxytocin. TEST-TAKING TIP: Oxytocin, the hormone of labor, also stimulates the uterus to contract in the postpartum period to reduce blood loss at the placental site. Oxytocin is the same hormone that regulates the milk ejection reflex. Therefore, whenever a mother breastfeeds, oxytocin stimulates her uterus to contract. In essence, breastfeeding naturally benefits the mother by contracting the uterus and preventing excessive bleeding.

Positive Homan's sign is indicative of:

DVT

Newborn screening (5 tests)

PKU (phenylketonuria) Hypothyroidism Galactosemia Hemoglobinopathies (sickle cell, thalassemia) Adrenal hyperplasia (need lifetime corticosteroids)

1st degree laceration

close to vaginal mucosa

Clinical manifestation of Subinvolution

continued lochia & vaginal bleeding pain heaviness large uterus

Hemabate side effects

diarrhea

Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is at high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.

The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation? 1. The mother reports a pain level of 4 on a 5-point scale. 2. The baby has been suckling for over 10 minutes. 3. The mother uses the cross-cradle hold while feeding. 4. The baby lies with the chin touching the under part of the breast.

A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

1. Clients should be strongly encouraged exclusively to breastfeed their babies to prevent engorgement. TEST-TAKING TIP: The lactating breast produces milk in response to being stimulated. When a feeding is skipped, milk is still produced for the baby. When the baby is not fed, breast congestion or engorgement results. Not only is engorgement uncomfortable, it also gives the body the message to stop producing milk, resulting in an insufficient milk supply.

A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible.

2. TEST-TAKING TIP: Mastitis is a breast infection that usually affects only one duct system. If the mother were to wean abruptly, milk stasis would occur, the bacteria would proliferate, and a breast abscess is likely to develop. The mother should feed her baby frequently, use warm soaks to promote milk flow, and notify her obstetrician. Antibiotics are usually prescribed to eradicate the bacteria.

A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following laboratory values indicates that the medication is effective? 1. Prothrombin time (PT): 12 sec (normal is 10-13 seconds). 2. International normalized ratio (INR): 2.5 (normal is 1-1.4). 3. Hematocrit 55%. 4. Hemoglobin 10 g/dL.

2. TEST-TAKING TIP: Coumadin interferes with the clotting of blood. The PT and/or INR will be monitored to determine whether the medication is effective. If the PT is more than 2 times normal or the INR is over 3, the client is at high riskfor hemorrhage.

A client who is post-cesarean section for severe pre-eclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check the carotid pulse.

3 TEST-TAKING TIP: The nurse should call a code as soon as he or she discovers a client who is nonresponsive. Immediately after calling the code, the nurse should stop the medications, begin rescue breathing, and provide chest compressions, if necessary, until the code team arrives. Calcium gluconate is the antidote to magnesium sulfate toxicity, but should only be administered if an order for the medication has been given by a primary healthcare provider.

The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? 1. 6. 2. 7. 3. 8. 4. 9.

A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for the past 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

A full-term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. Which of the following actions should the nurse perform at this time? 1. Feed the baby formula or breast milk. 2. Assess the baby's blood pressure. 3. Tightly swaddle the baby. 4. Monitor the baby's urinary output.

A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.

A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.

A nurse has administered Methergine (methylergonovine) 0.2 mg PO to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time.

A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis? 1. Baby's lips are flanged when latched. 2. Baby feeds every 4 hours. 3. Baby lost 12% of weight since birth. 4. Baby's tongue stays behind the gum line.

A nursing diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid volume deficit. Which of the following client care outcomes should be included in the nursing care plan? During the next 24 hour period, the baby will: 1. Urinate at least 6 times. 2. Breastfeed 2 to 4 times. 3. Lose less than 12% of the baby's birth weight. 4. Have an apical heart rate of 160 to 170 bpm.

A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate? "The baby received passive immunity through the placenta, plus the breast milk will also be protective." "The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox." "Chickenpox is transmitted by contact route so careful hand washing should prevent transmission." "Because chickenpox is a spirochetal illness, both the child and baby should receive the appropriate medications."

40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? 1. Encourage the parents to bond with their baby. 2. Notify the neonatologist of the finding. 3. Perform the gestational age assessment. 4. Place the baby under the overhead warmer.

A 2-day-old baby's blood values are: Blood type, O- (negative). Direct Coombs, negative. Hematocrit, 50%. Bilirubin, 1.5 mg/dL. The mother's blood type is A+. What should the nurse do at this time? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.

A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatologist of the significant weight loss. 3. Advise the mother to bottle feed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain? 1. The neonate's frenulum is attached to the tip of the tongue. 2. The baby's tongue forms a trough around the breast during the feedings. 3. The newborn's feeds last for 30 minutes every 2 hours. 4. The baby is latched to the nipple and to about 1 inch of the mother's areola.

A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take? 1. Nothing because this is an acceptable weight loss. 2. Advise the mother to supplement feedings with formula. 3. Notify the neonatologist of the excessive weight loss. 4. Give the baby dextrose water between breast feedings.

A baby admitted to the nursery was diagnosed with galactosemia from an amniocentesis. Which of the following actions must the nurse take? 1. Feed the baby a specialty formula. 2. Monitor the baby for central cyanosis. 3. Do hemoccult testing on every stool. 4. Monitor the baby for signs of abdominal pain.

A baby who is receiving phototherapy for hyperbilirubinemia must have a venipuncture to obtain a blood specimen. Which of the following nursing care actions should the nurse perform at this time? 1. Provide the baby with a sucrose-covered pacifier to suck on. Advise the baby's mother to leave the room while the procedure is being performed. Administer oxygen to the baby via face mask throughout the procedure. Remove the eye patches while the procedure is being performed.

A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights off for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket.

A baby, 30 weeks' gestation, is admitted to the neonatal intensive care unit. The mother had been treated with the tocolytic, IV magnesium sulfate, for the preceding 10 days. For which of the following laboratory findings should the nurse assess the neonate? 1. Hypocalcemia. 2. Hyperkalemia. 3. Hypochloremia. 4. Hypernatremia.

1. TEST-TAKING TIP: Neonates birthed to mothers who have received magnesium sulfate over a prolonged period of time are at high risk for hypocalcemia. In addition, prematurity, because of hypoparathyroid functioning, itself is a risk factor for hypocalcemia. Symptoms of the syndrome are similar to those seen in babies with hypoglycemia, for example, hypotonia, jitters, and seizures

The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication? 1. Inhibit the mother's active immune response. 2. Aggressively destroy the Rh antibodies produced by the mother. 3. Prevent fetal cells from migrating throughout the mother's circulation. 4. Change the maternal blood type to Rh-positive.

1. TEST-TAKING TIP: When a client receives RhoGAM, she receives passive Rh antibodies. If any Rh antigen is circulating in the mother's bloodstream, the antibodies will destroy it. As a result, there will be no antigen in the mother's body to stimulate her mast cells to have an active antibody response. In essence, therefore, RhoGAM is injected to inhibit the client's immune response.

A nurse is performing a postpartum assessment on a client on postpartum day one. The nurse notes the following four signs/symptoms. The nurse should report which of the signs/symptoms to the client's healthcare practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1. Foul-smelling lochia is a sign of endometritis.

A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's nipples are soft to the touch. 2. The baby swallows after every fifth suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

1. If the woman has manually removed milk from her breasts, her nipples will soften to the touch. TEST-TAKING TIP: This client is complaining of engorgement. The baby is having difficulty latching because the breast is inflamed, making the nipple tense and short. When the woman manually removes a small amount of the foremilk, the nipple becomes easier for the baby to grasp.

Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby who exhibits which of the following? 1. Intercostal retractions. 2. Erythema toxicum. 3. Pseudostrabismus. 4. Vernix caseosa.

1. Intercostal retractions are symptomatic of respiratory distress syndrome.

A client is receiving a blood transfusion after the delivery of a placenta accreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion? 1. "My lower back hurts all of a sudden." 2. "My hands feel so cold." 3. "I feel like my heart is beating fast." 4. "I feel like I need to have a bowel movement."

1. Sudden lower back pain is a sign of a transfusion reaction. TEST-TAKING TIP: If the client is receiving the wrong type of blood or is allergic to the blood, she will develop flank or kidney pain. Antibodies in the client's blood are likely destroying the donated blood. The transfusion should be stopped immediately and the reaction reported to the physician and to the blood bank.

A client has been receiving magnesium sulfate for severe pre-eclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104 bpm. 2. Urinary output 240 mL/12 hr. 3. Blood pressure 160/120. 4. Temperature 100°F.

A client is 3 days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective? 1. The client has had no seizures since delivery. 2. The client's blood pressure has dropped from 160/120 to 130/90. 3. The client's postoperative weight has dropped from 154 to 144 lb. 4. The client states that her headache is gone.

A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? 1. To promote melanin production in the neonatal period. 2. To provide heat production when the baby is hypothermic. 3. To protect the bony structures of the body from injury. 4. To provide calories for neonatal growth between feedings.

A mother and her 2-day-old baby are preparing for discharge. Which of the following situations would require the baby's discharge to be cancelled? 1. The parents own a car seat that only faces the rear of the car. 2. The baby's bilirubin is 19 mg/dL. 3. The baby's blood glucose is 65 mg/dL. 4. There is a large bluish spot on the left buttock of the baby.

A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? Hemolysis of neonatal red blood cells by the maternal antibodies. Physiological destruction of fetal red blood cells during the extrauterine period. Pathological liver function resulting from hypoxemia during the birthing process. Delayed meconium excretion resulting in the production of direct bilirubin.

A newborn nursery nurse notes that a 36-hour-old baby's body is jaundiced. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? It is administered to prevent the development of neonatal cataracts. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. The medicine must be administered immediately upon delivery of the baby. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.

An infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following? 1. Jaundice. 2. Jitters. 3. Erythema toxicum. 4. Subconjunctival hemorrhages.

A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? 1. Carotid. 2. Radial. 3. Brachial. 4. Pedal.

On admission to the maternity unit, it is learned that a mother has smoked two packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following? Breastfeeding is contraindicated if the mother smokes cigarettes. Breastfeeding is protective for the baby and should be encouraged. A two-pack-a-day smoker should be reported to child protective services for child abuse. A mother who admits to smoking cigarettes may also be abusing illicit substances.

The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug? 1. Monitor the urinary output hourly. 2. Supervise while the woman holds her newborn. 3. Position the woman slightly elevated on her left side. 4. Ask any visitors to leave the room.

2 TEST-TAKING TIP: Benadryl is an antihistamine. One of the common side effects of Benadryl as well as morphine is sedation. It is very likely that this client will fall asleep while holding the baby. The nurse, therefore, should supervise the mother while she holds her baby.

A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high-Fowler position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action? 1. Postpartum hemorrhage. 2. Severe postural headache. 3. Pruritic skin rash. 4. Paralytic ileus.

2 TEST-TAKING TIP: Postpartum hemorrhage, pruritic rash, and paralytic ileus are complications seen in post-cesarean clients, whether they received general anesthesia, epidural anesthesia, or spinal anesthesia. Only spinal clients, most notably those who elevate soon after surgery, are at high risk for postural headaches.

A client is seeking preconception counseling. She has type 1 diabetes mellitus and is found to have an elevated glycosylated hemoglobin (HgbA1c) level. Before actively trying to become pregnant, she is strongly encouraged to stabilize her blood glucose to reduce the possibility of her baby developing which of the following? 1. Port wine stain. 2. Cardiac defect. 3. Hip dysplasia. 4. Intussusception.

2 The incidence of cardiac defects and neural tube defects is high in infants born to diabetic mothers.

A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing, because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.

2. TEST-TAKING TIP: The hypertensive illnesses of pregnancy can develop at any time after 20 weeks' gestation through about 2 weeks postpartum. This client is exhibiting a late onset of pre-eclampsia— markedly elevated blood pressure and hyperreflexia. The physician should be notified as soon as possible of the changes.

A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? 1. Hepatitis B immune globulin in a second syringe. 2. Sterile water to dilute the vaccine before injecting. 3. Epinephrine in case of severe allergic reactions. 4. Oral syringe because the vaccine is given by mouth.

A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose? 1. Vitamin K. 2. Protamine. 3. Vitamin E. 4. Mannitol.

2. Protamine is the antidote for heparin overdose.

A baby has been admitted to the neonatal nursery whose mother is hepatitis B-surface antigen positive. Which of the following actions by the nurse should be taken at this time? 1. Monitor the baby for signs of hepatitis B. 2. Place the baby on contact isolation. 3. Obtain an order for the hepatitis B vaccine and the immune globulin. 4. Advise the mother that breastfeeding is absolutely contraindicated.

A breastfeeding woman calls the pediatric nurse with the following complaint: "I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? 1. "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." "Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula." "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." "In addition to giving the baby formula, you should wear a surgical face mask when you are around him."

A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes.

A full-term baby's bilirubin level is 12 mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery with complaints of burning on urination. 2. PP2 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO4 from cesarean delivery with complaints of firm and painful breasts.

A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place the child in an isolette. 2. Administer oxygen. 3. Swaddle the baby in a blanket. 4. Apply pulse oximeter.

After advising the parents of a 1-day-old baby that the baby must have a "heart defect test," the mother states, "Why? My baby is healthy. The pediatrician told me so." Which of the following responses by the nurse is appropriate? "I must have misread the name on the chart. It must be another baby who has to have the test." "We do this test on all of the babies before discharge, and I'm sure your baby's heart is healthy." "This is a screening test done on all babies. It is performed to find any possible heart problems before babies are discharged." "Your baby just had some minor symptoms that need to be checked. The test won't hurt the baby."

Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist? 1. 16-hour-old baby who has yet to pass meconium. 2. 16-hour-old baby whose blood glucose is 50 mg/dL. 3. 2-day-old baby who is breathing irregularly at 70 breaths per minute. 4. 2-day-old baby who is excreting a milky discharge from both nipples.

In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. The calf of one of the woman's legs is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purple.

The following four babies are in the neonatal nursery. The nurse should report to the neonatologist that which of the babies should be seen? 1. 1-day-old, HR 100 beats per minute, in deep sleep. 2. 2-day-old, T 97.7°F/36.5°C, slightly jaundiced. 3. 3-day-old, breastfeeding every 4 hours, jittery. 4. 4-day-old, crying, papular rash on an erythematous base.

The nurse assesses a newborn as follows: Heart rate: 70 Respirations: weak and irregular Tone: flaccid Color: pale Baby grimaces when a pediatrician attempts to insert an endotracheal tube What should the nurse calculate the baby's Apgar score to be?

The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings? 1. Temperature is elevated, a sign of infection. 2. Pulse is too low, a sign of vagal pathology. 3. Respirations are too low, a sign of medication toxicity. 4. Blood pressure is elevated, a sign of pre-eclampsia.

The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? 1. During the neonatal period, babies absorb fat-soluble vitamins poorly. 2. Breast milk and formula contain insufficient quantities of vitamin K. 3. The neonatal gut is sterile. 4. Vitamin K prevents hemolytic jaundice.

Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5°F /35.8°C? 1. Blood glucose of 50 mg/dL. 2. Acrocyanosis. 3. Tachypnea. 4. Oxygen saturation of 96%.

3 Babies who have cold stress syndrome will develop respiratory distress. One symptom of the distress is tachypnea. TEST-TAKING TIP: The neonate exhibits physiological characteristics that are very different from the older child or adult. For example, normal blood glucoses are lower in neonates than in the older child and adult and acrocyanosis is normal for a neonate's first day or two.

A 6-month-old child developed kernicterus immediately after birth. Which of the following tests should be done to determine whether or not this child has developed any sequelae to the illness? 1. Blood urea nitrogen and serum creatinine. 2. Alkaline phosphatase and bilirubin. 3. Hearing testing and vision assessment. 4. Peak expiratory flow and blood gas assessments.

3 Because the central nervous system (CNS) may have been damaged by the high bilirubin levels, testing of the senses as well as motor and cognitive assessments are appropriate. TEST-TAKING TIP: Kernicterus is the syndrome that develops when a neonate is exposed to high levels of bilirubin over time. The bilirubin crosses the blood-brain barrier, often leading to toxic changes in the CNS. The term sequelae refers to the disorders that result after an individual has experienced a disease or injury.

A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9°F /36.1°C. Which of the following could explain this finding? 1. This is a normal temperature for a preterm neonate. 2. Axillary temperatures are not valid for preterm babies. 3. The supply of brown adipose tissue is incomplete. 4. Conduction heat loss is pronounced in the baby.

3 Preterm babies are born with an insufficient supply of brown adipose tissue that is needed for thermogenesis, or heat generation. TEST-TAKING TIP: It is important for the test taker not to read into questions. Even though conduction can be a means of heat loss in the neonate and, more particularly, in the premature, there are three other means by which neonates lose heat— radiation, convection, and evaporation. Conduction could be singled out as a cause of the hypothermia only if it were clear from the question that conduction was the cause of the problem.

A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist? 1. Umbilical cord with three vessels. 2. Diamond-shaped anterior fontanelle. 3. Cryptorchidism. 4. Café au lait spot.

3 Undescended testes—cryptorchidism—is an unexpected finding. It is one sign of prematurity.

Which of the following neonates is at highest risk for cold stress syndrome? 1. Infant of diabetic mother. 2. Infant with Rh incompatibility. 3. Postdates neonate. 4. Down syndrome neonate.

3. Postdates babies are at high risk for cold stress syndrome because while still in utero they often metabolize the brown adipose tissue for nourishment when the placental function deteriorates. TEST-TAKING TIP: Cold stress syndrome results from a neonate's inability to create heat through metabolic means. In lieu of food intake, brown adipose tissue (BAT) and glycogen stores in the liver are the primary substances used for thermogenesis. The test taker can then deduce that the infant who is most likely to have poor supplies of BAT and glycogen is the postdates infant.

A preterm infant has a patent ductus arteriosus (PDA). Which of the following explanations should the nurse give to the parents about the condition? 1. Hole has developed between the left and right ventricles. 2. Hypoxemia occurs as a result of the poor systemic circulation. 3. Oxygenated blood is reentering the pulmonary system. 4. Blood is shunting from the right side of the heart to the left.

3. There is a left to right shunt of blood with a PDA, resulting in oxygenated blood reentering the pulmonary system. TEST-TAKING TIP: The ductus arteriosus is a fetal circulatory duct that connects the pulmonary artery with the aorta. In utero, the blood is being oxygenated through the placenta, precluding the need for the blood to enter the lungs. In extrauterine life, however, the duct should close to create a one-way, intact system. When a ductus arteriosus stays open, a left to right shunt develops (because the left side of the heart is stronger than the right side of the heart), forcing the blood to reenter the lungs.

A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective? 1. Skin color is pink. 2. Vital signs are normal. 3. Glucose levels are stable. 4. Blood clots after heel sticks.

A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician? 1. If the baby feeds 8 to 12 times each day. 2. If the baby urinates 6 to 10 times each day. 3. If the baby has stools that are watery and bright yellow. 4. If the baby has eyes and skin that are tinged yellow.

A baby born by vacuum extraction has been admitted to the well-baby nursery. The nurse should assess this baby for which of the following? 1. Pedal abrasions. 2. Hypobilirubinemia. 3. Hyperglycemia. 4. Cephalhematoma.

A baby is born to a mother who was diagnosed with oligohydramnios during her pregnancy. The nurse notifies the neonatologist to order tests to assess the functioning of which of the following systems? 1. Gastrointestinal. 2. Hepatic. 3. Endocrine. 4. Renal.

A newly delivered mother states, "I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best response by the nurse? "I understand that being good for so many months can become very frustrating." "Even if you bottle feed the baby, you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health." "Alcohol can be consumed at any time while you are breastfeeding." "You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again."

A nurse determines that which of the following is an appropriate short-term goal for a full-term, breastfeeding neonate? 1. The baby will regain birth weight by 4 weeks of age. 2. The baby will sleep through the night by 4 weeks of age. 3. The baby will stool every 2 to 3 hours by 1 week of age. 4. The baby will urinate 6 to 10 times per day by 1 week of age.

A woman who has just delivered has decided to bottle feed her full-term baby. Which of the following should be included in the patient teaching? 1. The baby's stools will appear bright yellow and will usually be loose. 2. The bottle nipples should be enlarged to ease the baby's suckling. 3. It is best to heat the baby's bottle in the microwave before feeding. 4. It is important to hold the bottle so as to keep the nipple filled with formula.

The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist? The eyes cross and uncross when they are open. The ears are positioned in alignment with the inner and outer canthus of the eyes. Axillae and femoral folds of the baby are covered with a white cheesy substance. The nostrils flare whenever the baby inhales.

The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? 1. The client states that the pain has decreased. 2. The nurse hears the baby swallow after each suck. 3. The baby's jaws move up and down once every second. 4. The baby's cheeks move in and out with each suck.

The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2°F. 2. White blood cell count of 14,500 cells/mm . 3. Diaphoresis during the night. 4. Malodorous lochial discharge.

A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions should the nurse take at this time? 1. Discontinue the phototherapy. 2. Notify the healthcare practitioner. 3. Take the baby's temperature. 4. Assess the baby's skin integrity.

4 The stools can be very caustic to the baby's delicate skin. The nurse should cleanse the area well and inspect the skin for any sign that the skin is breaking down. TEST-TAKING TIP: The test taker must know the difference between signs that are normal and those that reflect a possible illness. Although green stools can be seen with diarrheal illnesses, in this situation, the green stools are expected. The green stools are due to the increased bilirubin excreted and not related to an infectious state.

A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary healthcare provider.

4. Because of the heavy lochia, the nurse should notify the woman's healthcare provider. TEST-TAKING TIP: The nurse must do some detective work when observing unexpected signs/symptoms. This client is bleeding more heavily than the nurse would expect. When the nurse assesses the two most likely sources of the bleeding—the fundus and the perineal sutures—normal findings are noted. The next most likely source of the bleeding—a laceration in the birth canal—is unobservable to the nurse because performing a postpartum internal examination is not a nursing function. The nurse, therefore, must notify the healthcare practitioner of the problem.

Route of administration: Cytotec

in the rectum

Four 38-week-gestation gravidas have just delivered. Which of the babies should be monitored closely by the nurse for respiratory distress? 1. The baby whose mother has diabetes mellitus. 2. The baby whose mother has lung cancer. 3. The baby whose mother has mitral valve prolapse. 4. The baby whose mother has asthma.

1 The lung maturation of infants of diabetic mothers is often delayed. These babies must be monitored at birth for respiratory distress.

A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make? 1. Place a pillow in her lap. 2. Position the head of the baby in her elbow. 3. Put the baby on his back. 4. Move the breast toward the mouth of the baby.

The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? 1. Intercostal retractions. 2. Caput succedaneum. 3. Epstein pearls. 4. Harlequin sign.

The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are at high risk for which of the following? 1. Delayed speech development. 2. Otitis externa. 3. Poor parental bonding. 4. Choanal atresia.

The nurse is providing anticipatory guidance to a formula feeding mother who is concerned about how much formula she should offer her newborn infant at each feeding. The nurse would know that teaching was effective when the mother makes which of the following statements? "I should expect my baby to drink about 3 ounces of formula every 3 hours or so." "At the end of each pediatric appointment, the doctor will tell me how much formula to feed my baby." "By the time we go home from the hospital, I should expect him to drink at least 4 ounces per feeding." "I should give my baby enough formula to make him sleep for 4 hours between feedings."

The nursing management of a neonate with physiological jaundice should be directed toward which of the following client care goals? 1. The baby will exhibit no signs of kernicterus. 2. The baby will not develop erythroblastosis fetalis. 3. The baby will have a bilirubin of 16 mg/dL or higher at discharge. 4. The baby will spend at least 20 hours per day under phototherapy.

To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do? 1. Maintain the infant's temperature above 97.7°F/36.5°C. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

A nurse is advising the parents of a newborn regarding when they should call their pediatrician. Which of the following responses show that the teaching was effective? Select all that apply. 1. If the baby repeatedly refuses to feed. 2. If the baby's breathing is irregular. 3. If the baby has no tears when he cries. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4°F/38°C.

1 4 5

A 42-week-gestation baby, 2,400 grams, whose mother had no prenatal care is admitted into the NICU. The neonatologist orders blood work. Which of the following laboratory findings would the nurse expect to see? 1. Blood glucose 30 mg/dL. 2. Leukocyte count 1,000 cells/mm . 3. Hematocrit 30%. 4. Serum pH 7.8.

1 This baby is small for gestational age. Full-term babies (40 weeks' gestation) should weigh between 2,500 and 4,000 grams. It is very likely that this baby used up his or her glycogen stores in utero because of an aging placenta. An aging placenta is unable to deliver sufficient nutrients to the fetus. As a result the fetus must use his or her glycogen stores to sustain life and, therefore, is at high risk for hypoglycemia after birth.

A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6 mg/dL. Which of the following would the nurse expect the neonatologist to order for the baby at this time? 1. To be placed under phototherapy. 2. To be discharged home with the parents. 3. To be prepared for a replacement transfusion. 4. To be fed glucose water between routine feeds.

A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.

A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? 1. Put the baby's diapers on as tightly as possible. 2. Apply light pressure to the area with sterile gauze. 3. Call the physician who performed the surgery. 4. Assess the baby's heart rate and oxygen saturation.

A baby is just delivered. Which of the following physiological changes is of highest priority? 1. Thermoregulation. 2. Spontaneous respirations. 3. Extrauterine circulatory shift. 4. Successful feeding.

A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." "It is too early for rice cereal, but I would recommend giving the baby a bottle of formula at night." "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz, 21 inches long, TPR: 96.6°F/35.9°C, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following nursing actions is of highest importance? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2 TEST-TAKING TIP: The test taker should note that this baby is macrosomic and hypothermic, both of which make the baby at high risk for hypoglycemia. Plus, jitters are a classic symptom in hypoglycemic babies. To make an accurate assessment of the problem, the baby's glucose level must be assessed.

Four babies are born with distinctive skin markings. Identify which marking matches its description: 1. Café au lait spot 2. Hemangioma 3. Mongolian spots 4. Port wine stain A. Raised, blood vessel-filled lesion. B. Flat, sharply demarcated red-to-purple lesion. C. Multiple grayish-blue, hyperpigmented skin areas. D. Pale tan- to coffee-colored marking.

D A C B

A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding? 1. Holding the baby in the en face position. 2. Pushing down on the baby's lower jaw. 3. Tickling the baby's lips with the nipple. 4. Giving the baby a trial bottle of formula.

The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? When the cheek of the baby is touched, the newborn turns toward the side that is touched. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? 1. Failed lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement? 1. Maintain the client in left lateral recumbent position. 2. Teach sitz bath use on second postoperative day. 3. Perform active range-of-motion exercises until ambulating. 4. Assess central venous pressure during first postoperative day.

A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is at much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression.

3 TEST-TAKING TIP: Both spinal anesthesia and epidural anesthesia are forms of regional anesthesia. The same medication is used and it is placed at the same vertebral level in both instances. Only spinal anesthesia is administered into the spinal space, leaving a wound through which spinal fluid can escape. When spinal fluid is lost from the spinal canal, clients are at high risk for developing postural headaches, also called spinal headaches, because of the change in pressure in the spinal canal.

A newborn admitted to the nursery has a positive direct Coombs test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters. 2. Assess the blood glucose level. 3. Assess the rectal temperature. 4. Monitor the baby for jaundice

Methods of heat loss: Conduction

Contact with cold objects, hands, scale

Methods of heat loss: Convection

Drafts from open doors, air conditioner

Methods of heat loss: Radiation

Near cold surfaces, window, walls, crib

Physiologic vs. pathologic jaundice: -bili lights are not always indicated

physiologic

Hemabate is Contraindicated in?

pre-clampsia, high BP

Puerperal phases: Letting go

relinquish the expectations of birth experience -sense of disappointment (ie. Emergency c section) -sense of grief -anxiety

Cause: subinvolution

retained placenta fragments or infection

Puerperal phases: Taking hold

several days -mom's more independent -usually discharged -best time to get instructions

4th degree laceration/episiotomy

torn into rectum

2nd degree laceration

vaginal mucosa into deeper tissue (muscle)

Methods of heat loss: Evaporation

wet diaper, skin, hair

A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? Select all that apply. 1. Hyperthermia. 2. Diarrhea. 3. Hypotension. 4. Palpitations. 5. Anasarca.

1 2 TEST-TAKING TIP: Hemabate is an oxytocic agent that acts on the myometrial tissue of the uterus. During the postpartum it acts directly at the site of placental separation to stop uncontrolled bleeding. Hemabate is a type of prostaglandin.

A macrosomic baby in the nursery is suspected of having a fractured clavicle from a traumatic delivery. Which of the following signs/symptoms would the nurse expect to see? Select all that apply. 1. Pain with movement. 2. Hard lump at the fracture site. 3. Malpositioning of the arm. 4. Asymmetrical Moro reflex. 5. Marked localized ecchymosis.

1 2 3 4

A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply. 1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 4. Obtain an infusion bag of dextrose and water. 5. Document the time the infusion begins.

1 2 3 5

The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the clients who had which of the following deliveries state that they understand why they must receive a RhoGAM injection? Select all that apply. 1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 4. Birth of Rh-negative twins at 35 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby.

1 2 3 5

The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select all that apply. 1. Hypothyroidism. 2. Sickle cell disease. 3. Galactosemia. 4. Cerebral palsy. 5. Cystic fibrosis.

1 2 3 5

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? Select all that apply. 1. Gently massage the areas toward the nipple, especially during feedings. 2. Apply warmth to the areas during feedings. 3. Alternate bottle feedings with breast feedings. 4. Apply lanolin ointment to the areas after each and every breastfeeding. 5. Feed from the affected breast first.

1 2 5

During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select all that apply. 1. Pain. 2. Warmth. 3. Discharge. 4. Ecchymosis. 5. Redness.

1 2 5 TEST-TAKING TIP: Postpartum clients are at high risk for deep vein thrombosis (DVT). At each postpartum assessment the nurse assesses the calves for signs of the complication, that is, those seen in any inflammatory response: pain, warmth, redness, and edema. If the signs/ symptoms are noted, the nurse should request an order from the primary healthcare practitioner for diagnostic tests to be performed, such as a Doppler series.

A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. 1. Untreated, active tuberculosis (TB). 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis.

1 3 A mother with active, untreated TB should be separated from her baby until the mother has been on antibiotic therapy for about 2 weeks. She can, however, pump her breast milk and have it fed to the baby through an alternate feeding method. Mothers who are HIV positive are advised not to breastfeed because there is an increased risk of transmission of the virus to the infant.

A nurse is performing a postpartum assessment on a client who delivered vaginally. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

1 3 4 5 BUBBLEHE: B—breasts; U—uterus; B—bladder; B—bowels and rectum (for hemorrhoids and too inquire about most recent bowel movement); L—lochia; E—episiotomy (and perineum); H—Hormones (for emotions); and E—extremities. It is important to note that Homans sign is no longer recommended. Rather, careful inspection of the calves without dorsiflexing the foot for signs of DVT should be performed.

The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? Select all that apply. 1. The parents count their baby's diapers. 2. The parents measure the baby's intake. 3. The parents give one bottle of formula every day. 4. The parents take the baby to see the pediatrician. 5. The parents time the baby's feedings.

1 4

The nurse has provided teaching to a postop cesarean client who is being discharged on Colace (docusate sodium) 100 mg PO tid. Which of the following would indicate that the teaching was successful? 1. The woman swallows the tablets whole. 2. The woman takes the pills between meals. 3. The woman calls the doctor if she develops a headache. 4. The woman understands that her urine may turn orange.

1 Colace capsules should not be crushed, broken, or chewed.

Which of the following full-term babies requires immediate nursing intervention? 1. Baby with seesaw breathing. 2. Baby with irregular breathing with 10-second apnea spells. 3. Baby with coordinated thoracic and abdominal breathing. 4. Baby with respiratory rate of 52.

1 TEST-TAKING TIP: The test taker must be knowledgeable of the normal variations of neonatal respirations. Apnea spells of 10 seconds or less are normal, but apnea spells longer than 20 seconds should be reported to the neonatologist. Normally, when a baby breathes, his or her abdomen and chest rise and fall in synchrony. When they rise and fall arrhythmically, as in seesaw breathing, it is an indication that the baby is in respiratory difficulty.

A full-term, 36-hour-old neonate's bilirubin level is 13 mg/dL. Which of the following signs and symptoms would the nurse expect to see? Select all that apply. 1. Lethargy. 2. Jaundice. 3. Polyphagia. 4. Diarrhea. 5. Excessive yawning.

1 2

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1 TEST-TAKING TIP: A hematoma is a collection of blood under the skin. Although hematomas are usually simple bruises, large collections of blood can occur. Because the blood is trapped under the skin, the most common symptom is pain from the blood pressing on the pain sensors.

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1 TEST-TAKING TIP: A mother whose blood type is O, the blood type that is antigen negative, will produce anti-A and/or anti-B antibodies against blood types A and/or B, respectively. The anti-A (and/or anti-B) that passes into the baby's bloodstream via the placenta can attack the baby's red blood cells if he or she is type A or B. As a result of the blood cell destruction, the baby becomes jaundiced.

The physician declares after delivering the placenta of a client during a cesarean section that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2,000 mL. 2. Blood pressure of 160/110. 3. Jaundiced skin color. 4. Shortened prothrombin time.

1. TEST-TAKING TIP: A placenta accreta's chorionic villi burrow through the endometrial lining into the myometrial lining. Separation of the placenta from the uterine wall is severely hampered. Clients often lose large quantities of blood, and it is not uncommon for the physician to have to perform a hysterectomy to control the bleeding. Clients who have had multiple uterine scars are especially at high risk for this problem. If the test taker were unfamiliar with placenta accreta, he or she could deduce the answer because the placenta is highly vascular and only one answer referred to a vascular issue. The average blood loss during a cesarean delivery is 1,000 mL.

A mother, G6 P6006, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.

2 (macrosomic baby)

A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform to achieve effective breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

2 3 4

The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply. 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen. 5. Flaring of the nares during inspiration.

2 5

A nurse is caring for the following four laboring patients. Which clients should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. 1. G1 P0000, delivered a fetal demise at 29 weeks' gestation. 2. G2 P1001, prolonged first stage of labor. 3. G2 P0010, delivered by cesarean section for failure to progress. 4. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate. 5. G4 P3003, with a succenturiate placenta.

2 5 2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH). 5. Clients with a succenturiate placenta are at high risk for PPH. TEST-TAKING TIP: The muscles of the uterus of a client who has experienced a prolonged first stage of labor are fatigued. In the postpartum period, therefore, they may fail to contract fully enough to control bleeding at the site of placental separation. A succenturiate placenta is characterized by one primary placenta that is attached via blood vessels to satellite lobe(s). These clients must be monitored carefully for postpartum hemorrhage.

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42, oxygen saturation 96%. 2. Baby with Apgar 9/9, weight 4,660 grams. 3. Baby with temperature 98°F/36.7°C, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121.

2 Although the Apgar score—9—is excellent, the baby's weight—4,660 grams—is well above the average of 2,500 to 4,000 grams. Babies who are large for gestational age are at high risk for hypoglycemia.

A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

2. This is the best response. A right mediolateral episiotomy is angled away from the perineum and rectum.

A baby has just been born to a type 1 diabetic mother who has retinopathy and nephropathy. Which of the following neonatal findings would the nurse expect to see? 1. Hyperalbuminemia. 2. Polycythemia. 3. Hypercalcemia. 4. Hypoinsulinemia.

2 Because the placenta is likely to be functioning less than optimally, it is highly likely that the baby will be polycythemic. The increase in red blood cells would improve the baby's oxygenation in utero. TEST-TAKING TIP: The test taker must be familiar with the pathology of diabetes and its effect on pregnancy. Although infants of diabetic mothers (IDMs) are usually macrosomic as a result of increased plasma glucose levels, when mothers have vascular damage, the placenta functions poorly. The IDM consequently may be small for gestational age with intrauterine growth restriction and polycythemia from the poor nourishment and oxygenation.

Four babies in the well-baby nursery were born with congenital defects. Which of the babies' complications developed as a result of the delivery method? 1. Clubfoot. 2. Brachial palsy. 3. Gastroschisis. 4. Hydrocele.

2 Brachial palsy can result from either a traumatic vertex or breech delivery. TEST-TAKING TIP: When babies are born with unexpected findings, the nurse must be familiar not only with the implications of the anomalies but also with an understanding of the etiology of the anomalies. If the anomaly were a result of birth trauma, the nurse must be able to clearly and accurately communicate to the parents the source of the birth injury without communicating an opinion on any potential blame for the problem.

The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

2. It is important for the nurse to notify the physician. The client is bleeding more than she should after the delivery. TEST-TAKING TIP: The nurse must act as a detective to determine why he or she is seeing symptoms. In this scenario, the uterus is contracted and at the expected location—that is, firm at the umbilicus. The lochia flow, however, is heavy. The nurse must notify the practitioner for assistance because the bleeding may be due to a tissue laceration. There is no additional action the nurse can take at this time.

Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.

2. There is evidence to show that women who breastfeed their babies are less likely to develop type 2 diabetes later in life. TEST-TAKING TIP: Breastfeeding has many beneficial properties for both mothers and babies. It is a nursing responsibility to provide couples with the knowledge so that they can make fact-based decisions about how they will feed their babies.

A child has been diagnosed with a small ventricular septal defect (VSD). Which of the following symptoms would the nurse expect to see? 1. Cyanosis and clubbing of the fingers. 2. Respiratory distress and extreme fatigue. 3. Systolic murmur with no other obvious symptoms. 4. Feeding difficulties with marked polycythemia

3 TEST-TAKING TIP: The VSD—an opening between the ventricles of the heart—is the most common acyanotic heart defect seen. The defect leads to a left-to-right shunt because the left side of the heart is more powerful than the right side of the heart, causing a murmur. Small VSDs rarely result in severe symptoms and, in fact, often close over time without any treatment.

A gestational diabetic client who delivered yesterday is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time? 1. "Monitor your blood glucose five times a day until your 6-week checkup." 2. "I will teach you how to inject insulin before you are discharged." 3. "Daily exercise will help to prevent you from becoming diabetic in the future." 4. "Your baby should be assessed every 6 months for signs of juvenile diabetes."

3 TEST-TAKING TIP: Women who develop gestational diabetes are at high risk for developing type 2 diabetes. They should be encouraged to eat healthy foods and to exercise to prevent the onset of the chronic disease or, at the very least, to delay its onset.

A neonate has IUGR secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? Select all that apply. 1. Thrombocytopenia. 2. Neutropenia. 3. Polycythemia. 4. Hypoglycemia. 5. Hyperlipidemia.

3 4 TEST-TAKING TIP: Even if the test taker were unfamiliar with the expected laboratory findings of a neonate who had been born after living with an aging placenta, deductive reasoning could assist the test taker to choose the correct responses. Aging placentas function poorly, and, therefore, the fetuses receive less nutrition and oxygenation. The baby's body must then compensate for the losses by metabolizing glycogen and lipid stores and by producing increased numbers of red blood cells. The neonate, therefore, is often polycythemic, hypoglycemic, and hypolipidemic.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. 1. Hyperopia. 2. Gestational diabetes. 3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age.

3 4 5

When administering the neonatal screening for critical congenital heart defects (CCHD) on a baby in the well baby nursery, the nurse should perform which of the following actions? Select all that apply. 1. Obtain parental consent before performing the screen. 2. Take the baby's electrocardiogram. 3. Wait until the baby is at least 24 hours old. 4. Record the baby's heart rate fluctuations for one full minute. 5. Report pulse oximetry readings of 96% on the hand and 92% on the foot.

3 5

A nurse hears a heart murmur on a full-term neonate in the well-baby nursery. The baby's color is pink while at rest and while feeding. Which of the following cardiac defects is consistent with the nurse's findings? Select all that apply. 1. Transposition of the great vessels. 2. Tetralogy of Fallot. 3. Ventricular septal defect. 4. Pulmonic stenosis. 5. Patent ductus arteriosus.

3 5 3. Ventricular septal defect (VSD) is the most common cardiac defect in neonates. It is an acyanotic defect with a left to right shunt. Already oxygenated blood reenters the pulmonary system. 5. Patent ductus arteriosus (PDA) is a very common cardiac defect in preterm babies. It is an acyanotic defect with a left to right shunt. Already oxygenated blood reenters the pulmonary system. TEST-TAKING TIP: The names of cardiac defects are very descriptive. Oncethe test taker remembers the pathophysiology of each of the defects, it becomes clear how the blood flow is affected. Of the choices in this question, the defects that are acyanotic defects, that is, defects that allow blood to enter the lungs to be oxygenated, are the VSD and the PDA.

A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about? 1. The baby may develop a rash a week after the shot. 2. The baby may temporarily reject the breast milk. 3. The mother's milk supply may decrease precipitously. 4. The mother's joints may become painful and stiff.

4 TEST-TAKING TIP: Even though the benefits of receiving immunizations far outweigh the side effects of the medicines, anyone who receives a vaccine should be advised of the potential complications. It is especially important for mothers who are taking home newborn infants to receive anticipatory guidance regarding these changes and to be told that the baby's health will not be compromised.

A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. 3. Blocked milk duct. 4. Low milk supply.

4 TEST-TAKING TIP: The placenta produces the hormones of pregnancy, including estrogen and progesterone. When placental fragments are retained, those hormones are still being produced. Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. Women who have retained placental fragments, therefore, often complain of an insufficient milk supply for their babies. Women with retained placental fragments are also at high risk for postpartum hemorrhage and intrauterine infection.

A client who is 2 weeks postpartum calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but that today she is "bleeding and saturating a pad about every 1⁄2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bedrest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please go to the emergency department."

4 TEST-TAKING TIP: The quantity of lochia discharge is usually described as scant, moderate, or heavy. A heavy discharge is described as a discharge that saturates a pad in 1 hour or less. Because this client's lochia has already changed to alba (whitish), it is especially concerning that she is now experiencing a heavy lochia rubra (reddish) flow.

A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? 1. Place a pacifier in the baby's mouth. 2. Check the baby's diaper. 3. Have the mother feed the baby. 4. Assess the respiratory rate.

4 Grunting is often accompanied by tachypnea, another sign of respiratory distress.

A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 30 mg/dL, and after a feeding of the mother's expressed breast milk it is 35 mg/dL. Which of the following actions should the nurse take at this time? 1. Nothing, because the glucose level is normal for an infant of a diabetic mother. 2. Administer intravenous glucagon slowly over five minutes. 3. Feed the baby a bottle of dextrose and water and reassess the glucose level. 4. Notify the neonatologist of the abnormal glucose levels.

4 If the glucose level has not risen to normal as a result of the feeding, the nurse should notify the physician and anticipate that the doctor will order an intravenous of dextrose and water.

A 42-week-gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following neonatal care actions by the nurse is critical at this time? 1. Bath to remove meconium-contaminated fluid from the skin. 2. Ophthalmic assessment to check for conjunctival irritation. 3. Rectal temperature to assess for septic hyperthermia. 4. Respiratory evaluation to monitor for respiratory distress.

4 Meconium aspiration syndrome (MAS) is a serious complication seen in post-term neonates who are exposed to meconium- stained fluid. Respiratory distress would indicate that the baby has likely developed MAS. TEST-TAKING TIP: Although meconium appears black in a newborn's diaper, it is actually a very dark green color. When diluted in the amniotic fluid, therefore, the fluid takes on a greenish tinge. Because meconium is a foreign substance, when aspirated by the baby, a chemical and, secondarily, a bacterial pneumonia often develop.

A baby has been admitted to the neonatal intensive care unit with a diagnosis of postmaturity. The nurse expects to find which of the following during the initial newborn assessment? 1. Abundant lanugo. 2. Flat breast tissue. 3. Prominent clitoris. 4. Wrinkled skin.

4 The post-term baby does have dry, wrinkled, and often desquamating skin. The baby's dehydration is secondary to a placenta that progressively deteriorates after 40 weeks' gestation. TEST-TAKING TIP: The test taker should be familiar with the characteristic presentations of preterm and postmature neonates. Studying the items on the New Ballard Scale and the corresponding gestational ages when the items are seen is an excellent way to associate certain characteristics with dysmature babies.

A baby is born to a type 1 diabetic mother. Which of the following laboratory values would the nurse expect the neonate to exhibit? 1. Plasma glucose 30 mg/dL. 2. Red blood cell count 1 million/mm . 3. White blood cell count 2,000/mm . 4. Hemoglobin 8 g/dL.

1 TEST-TAKING TIP: The fetus, responding to elevated glucose levels from the mother, produces large quantities of insulin. After the birth, however, the placenta no longer is providing the baby with the mother's glucose. It takes the baby some time to adjust his or her extrauterine insulin production to be in synchrony with the nutrients provided by the breast milk or formula feedings. Until the baby makes the adjustment, he or she will exhibit hypoglycemia (less than 40 mg/dL).

Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for tachypnea? 1. The baby whose mother cultured positive for group B streptococci during her third trimester. The baby whose mother has cerebral palsy. The baby whose mother was hospitalized for 3 months with complete placenta previa. The baby whose mother previously had a stillbirth.

1 Group B streptococci cause severe infections in the newborn. Neonates who are septic often develop signs of respiratory distress. Tachypnea is one sign of respiratory distress.

A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg PO, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic.

1. TEST-TAKING TIP: This client is complaining of an excessive amount of pain after having received a relatively large dose of ibuprofen. Because the perineum is edematous, the lochial flow is normal, and the pain level is well above that expected, the nurse should suspect that the client has developed a hematoma. The client should be assessed by her healthcare provider.

The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary healthcare provider to order a milk suppressant.

1. The client should apply ice packs to her axillae and breasts. TEST-TAKING TIP: Breast milk is produced in the glandular tissue of the breast. An adequate blood supply to the area is required for the milk production. When cold is applied to the breast, the blood vessels constrict, decreasing the blood supply to the area. This is a relatively easy, nonhazardous action that helps to suppress breast milk production.

A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make? 1. Integrity of the baby's uvula. 2. Presence of maternal nipple damage. 3. Presence of neonatal tongue injury. 4. The baby's breathing pattern.

A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? 1. "I am required by law to give the medicine." 2. "The medicine helps to prevent eye infections." 3. "The medicine promotes neonatal health." 4. "All babies receive the medicine at delivery."

The birth of a baby, weight 4,500 grams, was complicated by shoulder dystocia. Which of the following neonatal complications should the nursery nurse observe for? 1. Leg deformities. 2. Brachial palsy. 3. Fractured radius. 4. Buccal abrasions.

2 During a difficult delivery with shoulder dystocia, the brachial nerve can become stretched and may even be severed. The nurse should, therefore, observe the baby for signs of palsy. TEST-TAKING TIP: The key to answering this question is understanding the terminology. A shoulder dystocia is a difficult delivery when the shoulder fails to pass easily through the pelvis. Deformities are disfigurements or malformations. Although the arm and shoulder may be injured, the baby is not disfigured. A buccal abrasion would occur on the inside of the cheek.

An 18-hour-old baby with an elevated bilirubin level is placed under the bili-lights. Which of the following is an expected nursing action in these circumstances? 1. Give the baby oral rehydration therapy in place of all feedings. 2. Rotate the baby from side to back to side to front every two hours. 3. Apply restraints to keep the baby under the light source. 4. Administer intravenous fluids via pump per doctor orders.

2 Rotating the baby's position maximizes the therapeutic response because the more skin surface that is exposed to the light source, the better the results are.

A woman who received an intravenous analgesic 4 hours ago has had prolonged late decelerations in labor. She will deliver her baby shortly. Which of the following is the priority action for the delivery room nurse to take? 1. Preheat the overhead warmer. 2. Page the neonatologist on call. 3. Draw up Narcan (naloxone) for injection. 4. Assemble the oral ophthalmic antibiotic.

2 The neonatologist must be called to the delivery room so that he or she arrives before the baby is delivered. TEST-TAKING TIP: This is a prioritizing question. Although all of these actions may be performed by the nurse, only one is a priority. This baby is showing signs of fetal distress—prolonged late decelerations. The baby may need to be resuscitated. The nurse must, therefore, page the neonatologist so that he or she is present for the birth of the baby.

A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is the highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

2 This is the priority nursing diagnosis. Because the baby is macrosomic, the client is at high risk for uterine atony that could lead to heavy vaginal bleeding, possibly resulting in fluid volume deficit. TEST-TAKING TIP: If the test taker remembers CAB as taught in CPR class—circulation, airway, breathing—he or she would realize that the client's fluid volume—that is, circulation—must take precedence.

A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O- (negative), the baby's type is A+ (positive), and the direct Coombs test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week to receive her RhoGAM injection. 2. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital. 3. Notify the client that because her baby's Coombs test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

2. TEST-TAKING TIP: The administration of RhoGAM is the only way to prevent an Rh- (negative) client's body from mounting a full antibody response to the delivery of an Rh+ (positive) baby. It is malpractice for a nurse to discharge the client before she receives her injection or to delay the injection beyond the 72-hour deadline.

The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following? Molding of the baby's skull so that the baby could fit through her pelvis. Swelling of the tissues of the baby's head from the pressure of her pushing. The position that the baby took in her pelvis during the last trimester of her pregnancy. Small blood vessels that broke under the baby's scalp during birth.

4 Cephalhematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one-sided or bilateral and the swellings do not cross suture lines. TEST-TAKING TIP: The key to the correct response is the fact that the bulge has not crossed the suture lines. Although each of the answer options is a common finding in neonates, only one is consistent with the assessments made by the nurse.

Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate? 1. The neonate with a temperature of 98.9°F/37.2°C and weight of 3,000 grams. 2. The neonate with white spots on the bridge of the nose. 3. The neonate with raised white specks on the gums. 4. The neonate with irregular respirations of 72 and heart rate of 166.

4 The normal resting respiratory rate of a neonate is 30 to 60 and the normal resting heart rate of a neonate is 110 to 160. TEST-TAKING TIP: The test taker should not be overwhelmed by descriptions of findings. Although the descriptions of milia and Epstein pearls appear to be abnormal, the item writer has merely rephrased information in a different way. It is important, therefore, to stay calm and read and decipher the information in each of the possible options.

3rd degree laceration

extends into anal sphincter

Signs of Cervical laceration

firm fundus but significant vaginal bleeding

Uterine atony: management

fundal checks & massage express clots check bladder for fullness pitocin IV Methergine IM, Hemabate IM, or Cytotec PR

Physiologic vs. pathologic jaundice: -bili lights are ALWAYS required -more concerning one

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