Complicated NCLEX Questions

A client with pre-eclampsia is receiving magnesium sulfate and oxytocin IV to induce labor at 38 weeks. The nurse determines the magnesium sulfate has been effective after noting which effect on the client? a. Absence of seizures b. Lowered blood pressure c. Onset of sedation d. Stools that are soft

a. Absence of seizures Explanation: If decreased blood pressure occurs, it is not the intended effect of magnesium sulfate. Magnesium sulfate is a CNS depressant used to prevent seizure activity in the pre-eclamptic client. If sedation occurs, it is not the intended effect of magnesium sulfate. If stools are soft, it is not the intended effect of magnesium sulfate.

A client is hospitalized on the antepartum unit with premature rupture of membranes at 37 weeks' gestation. Which of the following routine physician orders would the nurse question for this client? a. Vital signs every shift b. Bedrest with bathroom privileges c. Diet as tolerated d. External fetal monitor prn

a. Vital signs every shift Explanation: The nurse would expect the client with premature rupture of membranes to be placed on bedrest, have a regular diet and have fetal monitoring ot prevent complications. There is no need to question this routine order. The client with ruptured membranes prior to the beginning of labor is at increased risk for ascending infection (chorioamnionitis). The client's temperature should be taken every 2-4 hours, to identify early signs of sepsis.

A pregnant client in the active phase of labor has contractions that occur every 3-4 minutes, are 35-seconds' duration and have mild intensity. What conclusion about the client's status does the nurse draw from this data? a. Tachysystolic uterine dysfunction b. Hypotonic uterine dysfunction c. Progressive labor pattern d. Normal uterine activity

b. Hypotonic uterine dysfunction Explanation: Tachysystolic uterine dysfunction would be characterized by long, strong contractions with little resting time between contractions. Hypotonic uterine dysfunction occurs most often during the active phase. It is characterized by contractions that have become further apart, less intense, and of shorter duration. Contractions are typically 2-3 minutes apart, strong, and last 45-60 seconds in the active phase of labor. Normal uterine contractions are typically 2-3 minutes apart, strong, and last 45-60 seconds in the active phase of labor. A progressive labor pattern would show contractions that get longer, stronger, and closer together.

The nurse caring for a client with a concealed abruptio placentae prepares to assess the client for which complication as a priority after delivery? a. Retained placental fragments b. Uterine atony c. Vaginal hematoma d. Urinary tract infection

b. Uterine atony Explanation: Retained placental fragments could occur in any client. Urinary tract infection could occur in any client. A concealed abruption could result in a Couvelaire uterus, which doesn't contract effectively after delivery, leading to uterine atony. Vaginal hematoma could occur in any client.

The nurse should be aware that pregnant women who practice substance abuse and present themselves for prenatal care: a. Must be reported to the authorities. b. Will lack appropriate parenting skills. c. Recognize the need for caring interventions. d. Are ready to kick their habit.

c. Recognize the need for caring interventions. Explanation: Assuming the client is ready to stop using drugs is an unrealistic assumption. Reporting the client to the authorities is punitive. Pregnancy presents an ideal time for nurses to reach out to substance-abusing clients in a caring way, since the client herself recognizes that she and her baby will benefit from prenatal care. Assuming the client will not have adequate parenting skills is judgmental

Which clinical focus is of highest priority for a client with a missed abortion who has developed disseminated intravascular coagulopathy (DIC)? a. Anxiety about possible death b. Grief regarding loss of fetus c. Risk for bleeding d. Risk for infection

c. Risk for bleeding Explanation: The client is likely to be experiencing grief related to fetal loss but this is a psychosocial concern that can be addressed once the client is physiologically stable. The client could experience infection but this risk is no greater than for other clients. The client with DIC is at risk for bleeding or hemorrhage which takes priority because of associated physiological consequences such as hypovolemia or shock. The client may or may not be concerned about death, but physiological interventions to stabi-lize the client would take priority.

The nurse anticipates that a pregnant client with a history of which health problems might benefit from a scheduled cesarean birth to have an improved outcome for the infant?Select all that apply. a. Diabetes mellitus b. Class I heart disease c. Systemic lupus erythematosus d. Human immunodeficiency virus e. Active genital herpes lesions

d, e Explanation: A client with diabetes mellitus does not require cesarean delivery based on this diagnosis alone. A client with active herpes lesions should undergo cesarean delivery to prevent transmission of the virus during vaginal birth. The chance of transmission of HIV is less than 1% if the infant is delivered by cesarean prior to membrane rupture. A client with systemic lupus erythematosus does not require cesarean delivery based on this diagnosis alone. A client with Class I heart disease does not require cesarean delivery based on this diagnosis alone.

The pregnant client is receiving oxytocin to induce labor. The nurse should monitor the client for which adverse maternal effects? Select all that apply. a. Bradycardia. b. Uterine hyperstimulation c. Dehydration d. Decreased urine output e. Jaundice

b, d Explanation: Bradycardia is a possible adverse effect for the fetus, not for the mother. The antidiuretic effect of oxytocin decreases water exchange in the kidney and reduces urinary output. The antidiuretic effect of oxytocin decreases water exchange in the kidney and reduces urinary output, leading to fluid overload rather than dehydration Jaundice is a possible adverse effect for the fetus rather than the mother. Oxytocin (Pitocin) stimulates uterine contractility; exceeding maximum doses or increasing doses too rapidly can result in uterine hyperstimulation.

Which nursing action would take priority when caring for the woman with a suspected ectopic pregnancy? a. Obtain surgical consent b. Monitoring vital signs c. Administering oxygen d. Providing emotional support

b. Monitoring vital signs Explanation: Oxygen administration is a possible later intervention. The client with a suspected ectopic pregnancy might be at risk for the development of hypovolemic shock. Assessment is the first step of the nursing process, and airway, breathing, and circulation are the priorities. Obtaining consent for surgery is the surgeon's responsibility. Providing emotional support is correct, but not the priority intervention

During vaginal examination, the nurse palpates the fetal head and a large, diamond-shaped fontanelle. The nurse documents the fetal presentation as which of the following? a. Shoulder b. Breech c. Vertex d. Brow

d. Brow Explanation: In shoulder presentations, fetal parts would feel soft and irregular. In breech presentation, fetal parts would feel soft and irregular. In vertex presentation, the back of the fetal head (occiput) and small, triangular fontanelle are palpated. In a brow presentation, the fetal forehead and the large, diamond-shaped anterior fontanelle are palpated during vaginal exam.

A client with type 1 diabetes mellitus gives birth. The postpartum nurse monitors the blood glucose level carefully, expecting that the client's insulin requirements in the first 24 hours after delivery will do which of the following? a. Gradually return to normal. b. Increase slightly. c. Stay the same as before delivery. d. Drop significantly.

d. Drop significantly. Explanation: The placenta produces human placental lactogen (hPL) and increased amounts of estrogen and progesterone. These hormones interfere with maternal glucose metabolism, and require increased insulin production or supplementation. As soon as the placenta is expelled, these hormone levels fall dramatically, and the mother might require no insulin at all or a very reduced dose in the first 24 hours.

A client at 24 weeks' gestation has been scheduled for an amniocentesis. Which actions should the nurse plan to take in the care of this client? Select all that apply. a. Have a consent signed for epidural analgesia. b. Instruct that an ultrasound machine will be used during the procedure. c. Monitor maternal vital signs and fetal heart rate during procedure. d. Assist the woman in assuming a supine position with a wedge under left hip. e. Explain that 60 mL of amniotic fluid will be withdrawn.

b, c, d Explanation: Maternal vital signs and FHR are monitored during procedure. The test is completed on an outpatient basis under guidance of ultrasound visualization. The client is positioned on her back with a wedge under her left hip to avoid hypotension from pressure of the uterus on the vena cava. Epidural analgesia is not used for the procedure. Approximately 15-20 mL of amniotic fluid are aspirated for the procedure.

The nurse concludes that a client is at risk for pre-eclampsia when the vital signs taken today show that the blood pressure has shown which pattern of elevation since the previous prenatal visit? a. 90/56 to 110/70 b. 122/70 to 138/82 c. 130/60 to 146/92 d. 134/74 to 138/88

c. 130/60 to 146/92 Explanation: A BP of 90/56 to 110/70 does not meet the criteria for either the systolic or diastolic BP reading. A systolic blood pressure of 140 mmHg and a diastolic blood pressure of 90 mmHg is diagnostic for pre-eclampsia. A BP of 122/70 to 138/82 does not meet the criteria for either the systolic or diastolic BP reading. A BP of 134/74 to 138/88 does not meet the criteria for either the systolic or diastolic BP reading.

The nurse determines that which potential problem should be a focus of care for a client undergoing an amniocentesis? a. Inadequate amniotic fluid volume b. Aspiration because of anesthesia c. Anxiety about well-being of fetus d. Dehydration because of NPO status

c. Anxiety about well-being of fetus Explanation: A client does not have to be NPO prior to amniocentesis. Amniocentesis does not require anesthesia, although a local anesthetic may be used to numb the skin before needle insertion. Most women view invasive antenatal testing with anxiety because of the reason for the test, the impending results, and concern about maternal and fetus complications. Because only 15-20 mL of fluid removed, the client is not at risk for having inadequate amniotic fluid volume.lications.

The nurse determines that a client understands what to expect during cesarean delivery when the client makes which statement?Select all that apply. a. "I may be given an antacid before surgery." b. "An indwelling (Foley) catheter will be inserted before surgery." c. "I will receive a blood transfusion during surgery." d. "My husband can be present during birth." e. "I will not need an IV, since I will have an epidural anesthesia."

a, b, d Explanation: A Foley catheter is inserted to prevent bladder damage during surgery. The client's husband or primary support person is usually present at the birth except in extreme emergencies. An antacid is administered to prevent aspiration of acidic gastric contents, thus reducing the risk of lung damage. Blood transfusions are not routinely given during cesarean sections. Although blood typing and screening are often ordered prior to surgery, it is seldom necessary for a client to receive a blood transfusion. IV lines are necessary for instillation of fluid, medications, and potential blood products during surgery.

A pregnant client with class II heart disease progressed through pregnancy without complications and is admitted to the hospital in active labor. Soon after admission, the client reports shortness of breath and the nurse auscultates lung crackles. The nurse anticipates administering which medication based on the client's history? Select all that apply. a. Penicillin b. Metoprolol c. Furosemide d. Digoxin e. Procainamide

a, c, d Explanation: Prophylactic antibiotics such as penicillin are given during labor to prevent bacterial endocarditis. An antihypertensive such as metoprolol would be used only as needed. A diuretic such as furosemide may help counteract the new signs of decreased cardiac output (crackles and shortness of breath). A cardiac glycoside such as digoxin may help counteract the new signs of decreased cardiac output (crackles and shortness of breath). An antidysrhythmic such as procainamide would be used only as needed.

A 34-year-old client comes to the emergency department with cramping and vaginal bleeding. She has missed two menstrual periods. Which statements by the nurse are most appropriate when the client is diagnosed with an incomplete abortion? Select all that apply. a. "I am so sorry. This must be difficult for you." b. "Did you really want to be pregnant now?" c. "The doctor will clean out your womb with a D and C." d. "You'll still be able to have children after this is over." e. "Would you like to speak with a hospital chaplain or counselor?"

a, e Explanation: The nurse should provide emotional support to all clients experiencing perinatal loss. This statement focuses on a follow-up medical procedure, and does not address the emotional needs of the client. This question is insensitive and minimizes the client's loss. This statement is insensitive to the current loss, and it also might not be true. Offering the client an opportunity to talk with another health care professional or clergy for additional help is supportive.

A client with heart disease has been prescribed digoxin during her pregnancy. The nurse evaluates that client teaching has been effective when the client makes which statement? a. "I will check my pulse, and not take the medication if it is less than 60." b. "I will not take antibiotics at the same time as this medication." c. "I will take this medication with a full glass of water before breakfast." d. "I will avoid eating foods high in potassium while taking this medication."

a. "I will check my pulse, and not take the medication if it is less than 60." Explanation: The client needs adequate potassium for myocardial function. Digoxin is a cardiac glycoside that increases cardiac output by increasing the strength of contraction of the myocardium and slowing the heart rate. A pulse rate lower than 60 is a serious adverse effect of the medication, and the dose should be withheld. Antibiotics are not contraindicated with digoxin. The drug may be given with or without food.

Which statement by the nurse is most therapeutic in talking with a client and her family following emergency cesarean birth? a. "I know you never expected this to happen. Maybe things will work out better next time." b. "You did so well throughout the delivery. I'm sorry I didn't have more time to explain things." c. "Your baby was really in danger. I think he is doing better now." d. "I'm sorry that you couldn't have a normal delivery."

b. "You did so well throughout the delivery. I'm sorry I didn't have more time to explain things." Explanation: This statement indicates that the birth was not normal, and can promote negative feelings about the infant or the experience. This statement could further frighten the family. Promoting a positive feeling about how well she was able to cope with an emergency cesarean delivery will positively influence the client's self-image and feelings about her ability to handle future pregnancies and births. Providing an opportunity for the client and her family to ask questions and to express feelings helps in dealing with any disappointment, anger, or guilt they might feel. Expressing hopes for the future does not help the client and family process this event.

The nurse caring for a high-risk client in labor observes the presence of variability of the fetal heart rate (FHR) of 10-12 beats per minute as recorded by the internal fetal monitor. What interpretation should the nurse make about the fetal condition or state? a. Fetal hypoxia b. Fetal well-being c. Uteroplacental insufficiency d. Umbilical cord compression

b. Fetal well-being Explanation: Hypoxia can cause loss of variability of the FHR. Variability of FHR indicates fetal well-being. The presence of variability is assessed by internal fetal monitoring, since there is less artifact that could be mistaken for variability of heart rate. Umbilical cord compression can cause severe variable decelerations or prolonged bradycardia of FHR. Uteroplacental insufficiency can cause late decelerations of FHR.

The client who has had a previous cesarean birth asks about vaginal birth after cesarean (VBAC). Which of the following factors from her history is a contraindication for VBAC? a. The previous cesarean was for breech presentation. b. The client had a classic uterine incision. c. The abdominal incision was vertical rather than transverse. d. An induction of labor is planned for this delivery.

b. The client had a classic uterine incision. Explanation: The reason for the previous cesarean is not of concern. A classical incision involves the upper uterine segment, and is more likely to separate or rupture with subsequent uterine contractions. The type of abdominal incision is not a concern, since it is not affected by uterine contractions. Induction is not a contraindication if managed judiciously.

Which condition of the pregnant client places her at increased risk for uterine inversion during the current labor and delivery? a. Forceps delivery of a previous infant b. Traction on the umbilical cord and vigorous fundal massage in the third stage c. Fundal pressure during delivery of the head and body d. Precipitous birth of less than 3 hours' duration

b. Traction on the umbilical cord and vigorous fundal massage in the third stage Explanation: Previous forceps delivery is not associated with inversion. Fundal pressure during delivery of head and body is not associated with inversion. Precipitous birth is not associated with inversion. Although not always preventable, uterine inversion can occur because of excessive traction on the umbilical cord during the third stage of labor with or without vigorous fundal massage to remove the placenta, especially if the placenta is implanted in the fundus.

An HIV-positive client in active labor with newly ruptured membranes is being transported to the hospital via ambulance. The nurse anticipates priority administration of which medication to this client? a. Immune globulin b. Zidovudine c. Oxytocin d. Antibiotics

b. Zidovudine Explanation: An antibiotic could be administered if the membranes were ruptured for an extended time before delivery. There is no indication in the question for immune globulin, which would provide passive immunity against a specific type of infection. There is no indication in the question for oxytocin, which would induce labor. The rate of transmission of HIV to the newborn decreases sharply if the mother is given prophylactic zidovudine orally during pregnancy and by IV during labor.

A prenatal client with type 1 diabetes mellitus asks the clinic nurse whether she will be able to breastfeed her baby. Which response by the nurse is most accurate? a. "You will have a lot of difficulty maintaining a stable blood sugar." b. "I think this is a good idea because it also prevents pregnancy." c. "Certainly, breastfeeding will be beneficial for both of you." d. "Breastfeeding is contraindicated for insulin-dependent moms."

c. "Certainly, breastfeeding will be beneficial for both of you." Explanation: Breastfeeding is not contraindicated for diabetic mothers. Breastfeeding should be encouraged because it benefits both the mother and her infant. Breastfeeding might or might not help prevent future pregnancy during lactation. Breastfeeding does not necessarily lead to loss of blood glucose control with careful management.

In addition to routine assessment and care, nursing care of the client who is receiving terbutaline to prevent premature labor should include assessing which items? a. Fetal heart tones every 30 minutes b. Oral temperature every 2 hours c. Breath sounds every 4 hours d. Deep tendon reflexes every 4 hours

c. Breath sounds every 4 hours Explanation: The frequency of assessment of oral temperature depends on the risk for infection. The frequency of assessment of fetal heart tones depends on the intensity and length of the drug therapy, as well as surrounding circumstances. Terbutaline, a beta-adrenergic agent, has many maternal and fetal side effects, including tachycardia, cardiac arrhythmias, and pulmonary edema. In addition to taking vital signs, the nurse should assess for pulmonary edema. Deep tendon reflex assessment is not indicated.

The nurse would assess the pregnant client with a history of multiple sexual partners for which complication of pregnancy of greatest concern in this situation? a. Rh incompatibility b. Premature rupture of membranes c. Ectopic pregnancy d. Pre-eclampsia

c. Ectopic pregnancy Explanation: The client with multiple partners is at high risk for sexually transmitted infections and ascending infection that can lead to blockage in the fallopian tubes. Ultimately, this process could lead to ectopic pregnancy. Premature rupture of membranes is not associated with multiple partners. The number of sexual partners does not influence development of preeclampsia. Rh incompatibility has to do with Rh blood type of the father.

The client has refused sedation ordered by the physician for hypertonic contractions and prolonged latent-phase labor for fear that her labor will stop. The nurse can help by explaining which of the following? a. Sedation will stop contractions that are uncoordinated, and will provide more time to determine if a cesarean delivery is needed. b. If contractions continue without cervical effacement and dilatation, the fetus is at risk for hypoxia. c. Sedation helps to provide needed rest, and allows time for the uterine contractions to become coordinated, so that labor is progressive. d. If the woman is experiencing true labor, contractions will not stop even with sedation.

c. Sedation helps to provide needed rest, and allows time for the uterine contractions to become coordinated, so that labor is progressive. Explanation: Prolonged latent-phase labor is associated with uncoordinated, hypertonic, and painful contractions that do little to dilate or efface the cervix. Maternal exhaustion and dehydration are concerns. Medical management is directed toward providing rest and hydration, and allowing time for contractions to become coordinated. Often, clients awaken from sedation in progressive labor. If the woman is experiencing true labor, contractions will not stop even with sedation does little to explain the rationale for sedation. There is very little risk to the fetus unless contractions are intense and < 2 minutes apart. It is too soon to anticipate the need for cesarean delivery.

Which of the following priority items should the nurse assess because of the potential impact on the laboring client's psychological status? a. Attitude about parenting b. Beliefs about health c. Self-image d. Relationship with the client's own mother

c. Self-image Explanation: Attitude about parenting has not been identified as having a significant impact during labor. Relationship with own mother has not been identified as having a significant impact during labor. Self-image refers to how a client feels about herself. A positive self-image enables a client to deal with labor and delivery realistically, even in the event of complications. Research has shown that self-image impacts the laboring client's psyche. Health beliefs have not been identified as having a significant impact during labor.

A client at 26 weeks' gestation experiencing a marginal abruptio placenta asks if the baby will be harmed. What should the nurse include in a response? a. "It may cause the fetus to develop hydrops." b. "It may cause a buildup of urine in the fetus, causing kidney damage." c. "It may cause a fetal anomaly." d. "It may decrease the amount of nutrients the fetus receives."

d. "It may decrease the amount of nutrients the fetus receives." Explanation: One of the major functions of the placenta is provision of nutrients to the fetus across the placenta membrane. An interference with the placenta circulation, such as abruptio placentae, impairs this ability. Another important function is removing metabolic waste from the fetus. While this takes place metabolically the fetus produces and excretes urine independently of the placenta. Hydrops is gross fetal edema related to hemolytic action, not placenta dysfunction. Anomalies usually occur in the first trimester when organogenesis occurs.

The nurse explains to a client who had a cervical cone biopsy several years ago that she is now at increased risk for which complication of pregnancy? a. Placenta previa b. Gestational trophoblastic disease c. Ectopic pregnancy d. Incompetent cervix

d. Incompetent cervix Explanation: The client who had a cervical cone biopsy is not at greater risk for ectopic pregnancy. Cervical trauma and scarring, such as from cervical cone biopsy, can result in cervical incompetence during pregnancy. The client who had a cervical cone biopsy is not at greater risk for gestational trophoblastic disease. The client who had a cervical cone biopsy is not at greater risk for placenta previa.

The nurse caring for a pre-eclamptic client discovers her on the bathroom floor having an eclamptic seizure. What are the nurse's priority actions? a. Turn the client on her back, and observe her movements. b. Insert a tongue blade, to prevent biting the tongue. c. Call the physician, and prepare for cesarean birth. d. Remain with the client, and call for help.

d. Remain with the client, and call for help. Explanation: The nurse remains with the client to prevent injury during the seizure. The physician can be called by another person or done after the seizure has ended and the client has been assessed. Insertion of a tongue blade is not recommended, because of the risk of injury to both nurse and client. The nurse remains with the client to prevent injury during the seizure. The client should be placed on her side, to avoid aspiration.

The nurse is assigned to a pregnant client who is having an amnioinfusion. In addition to fetal heart rate and contractions, the nurse monitors which of the following during the procedure?Select all that apply. a. Maternal vital signs b. Fetal movement c. Uterine tone d. Uterine overdistention e. Labor progress

a, c, d Explanation: Fetal movement does not need to be specifically assessed during this procedure. The uterus should be monitored for an elevated resting tone due to possible overinfusion of solution into the uterine cavity or trapping of infused solution behind a presenting part. The elevation in uterine tone can lead to fetal distress. Maternal vital signs are measured to determine physiological status. The progress of labor is not of concern during this procedure. The uterus should be monitored for overdistention because of possible fluid overinfusion or trapping of infused solution.

In preparing the client in labor for vacuum extraction, it is important to explain that the infant might initially have which appearance after delivery? Select all that apply. a. Edema of the caput b. Red marks on the face c. Edema of the face d. Bruising of the scalp e. Swelling of the eyes

a, d Explanation: Suction applied over the occiput commonly causes edema of the scalp or caput. Although it might appear to be a deformity of the fetal head, the edema disappears in 2-3 days. Suction applied over the occiput commonly causes bruising of the scalp, which will resolve.

The nurse interprets that a pregnant client understands the purpose and the procedure of external cephalic version when the client makes which statement? a. "After the baby is turned, I must remain in bed." b. "My baby's head will be turned slightly to make the delivery easier." c. "The procedure will be stopped if my baby shows signs of distress." d. "My doctor will place a hand inside my uterus and pull the baby into a head down position."

c. "The procedure will be stopped if my baby shows signs of distress." Explanation: External cephalic version involves abdominal manipulation to rotate the fetus from either a breech or shoulder presentation to vertex Version involves turning the fetal body, not just the head. Staying in bed after a version is not necessary. The procedure will be stopped immediately if there is maternal or fetal distress.

On performing Leopold's maneuver on a multiparous client in early labor, the nurse finds no fetal parts in the fundus or above the symphysis. The fetal head is palpated in the right mid quadrant. The nurse notifies the admitting physician and anticipates which of the following? a. An external version b. An internal version c. A cesarean delivery d. Prolonged labor

c. A cesarean delivery Explanation: Since the client is in labor, version is contraindicated. Findings on palpation are consistent with shoulder presentation or transverse lie. Vaginal delivery is not possible, so the nurse should anticipate cesarean section. Prolonged labor is irrelevant.

A pregnant client comes to the hospital at 36 weeks reporting that her "water broke," but denies any contractions. Which assessment data provides the nurse with the most reliable indication of premature rupture of membranes? a. Fluid from the perineum turns nitrazine paper dark blue. b. No membranes are felt on a sterile vaginal exam. c. A dried specimen shows a microscopic fern pattern. d. The client has a visible watery vaginal discharge.

c. A dried specimen shows a microscopic fern pattern. Explanation: During pregnancy, only amniotic fluid will dry to a ferning pattern. Urine occasionally might be alkaline, and turn nitrazine paper blue, or old nitrazine paper might be unreliable. Performing a vaginal exam places the client at unnecessary risk for an ascending infection, and feeling for membranes is unreliable. A watery vaginal discharge is not necessarily amniotic fluid.

The charge nurse in the labor and delivery unit has become overwhelmed with admissions and births. For which client can the charge nurse best delegate the needed care to a trusted certified nursing assistant (CNA) who is currently going to school to become a nurse? a. Determine the degree of cervical dilation for a client in active labor b. An obese laboring client who needs to have her fetal monitor adjusted c. A primigravida in early labor who needs to be helped to the bathroom d. A client in false labor who needs teaching about true versus false labor signs

c. A primigravida in early labor who needs to be helped to the bathroom Explanation: The Rationale should be as follows: "The registered nurse can safely delegate ambulating a client in early labor to the bathroom. The registered nurse is responsible to teach signs of false labor. The nurse is responsible to assess for cervical dilation. Adjustment of a fetal monitor is the responsibility of the registered nurse

The nurse anticipates that which complication of pregnancy would be most consistent with development of a sinusoidal fetal heart rate pattern during labor? a. Chorioamnionitis b. Pre-eclampsia c. Abruptio placentae d. Prolapsed cord

c. Abruptio placentae Explanation: A sinusoidal fetal heart rhythm is associated with fetal anemia, which could be associated with an abruption. Chorioamnionitis could result in other signs of fetal distress, such as tachycardia, loss of variability, and late decelerations. Pre-eclampsia could result in other signs of fetal distress, such as tachycardia, loss of variability, and late decelerations. Prolapsed cord could result in other signs of fetal distress, such as tachycardia, loss of variability, and late decelerations.

A client's amniotic fluid is greenish-tinged. The fetal presentation is vertex. Fetal heart rate (FHR) and uterine activity have remained within normal limits. At the time of delivery, the nurse should anticipate the need for which of the following? a. A transport isolette b. Emergency cesarean setup c. An infant laryngoscope and suction catheters d. Forceps

c. An infant laryngoscope and suction catheters Explanation: The infant is at risk for aspirating meconium at the time of delivery. Steps to prevent aspiration include thorough suctioning of the nasopharynx, including visualization of the vocal cords to remove meconium particles before the first breath. Forceps-assisted delivery is not necessary because of meconium-stained amniotic fluid. This may be needed soon after delivery if the newborn's condition warrants it, but it is not needed at the time of delivery. Meconium released by the fetus causes amniotic fluid to be greenish-tinged. Although the presence of meconium is associated with fetal distress, there is no evidence of immediate danger to the fetus during labor in this case.

A primigravida is hospitalized at 32 weeks' gestation after a second hemorrhage from a complete placenta previa. The client appears subdued and sad after learning she will remain hospitalized until delivery. She says she is worried about her husband, who will be at home alone much of the time. The nurse interprets the client's response as indicating which psychological state? a. Immaturity b. Denial c. Anxiety d. Ineffective coping

c. Anxiety Explanation: The client has stated that she is worried, which creates anxiety. The information presented does not represent denial. The information presented does not represent immaturity. There is not enough data to determine whether the client's coping is effective at this time.

A client with hyperemesis gravidarum found crying would most likely benefit from nursing care designed to address which nursing diagnosis? a. Ineffective coping related to unwanted pregnancy. b. Anticipatory grieving related to inevitable pregnancy loss. c. Anxiety related to effects of hyperemesis on fetal well-being. d. Imbalanced nutrition: more than body requirements related to pregnancy.

c. Anxiety related to effects of hyperemesis on fetal well-being. Explanation: The client experiences excessive vomiting, and would have the diagnosis of imbalanced nutrition: less than body requirements. The client with hyperemesis gravidarum is anxious or even fearful about the effects of her condition on the fetus. The etiology of hyperemesis is unknown, but the incidence is increased in conditions with increased hCG. With appropriate treatment, the prognosis is favorable for the fetus. There might be an emotional component, but there is no indication that this is an unwanted pregnancy.

The client is receiving intravenous magnesium sulfate at 2 grams/hr to stop premature labor. The nurse determines that the most important nursing assessments of this client include which of the following? a. Intake and output, level of consciousness, and blood pressure. b. Intake and output, blood pressure, and reflexes. c. Deep tendon reflexes, hourly urine output, and respiratory rate. d. Blood pressure, pulse, and uterine activity.

c. Deep tendon reflexes, hourly urine output, and respiratory rate. Explanation: Although blood pressure is a standard assessment for most antepartum clients, there is minimal blood pressure change, if any, associated with administration of magnesium sulfate. Early signs of magnesium toxicity that could lead to respiratory arrest are loss of patellar reflexes and decreased respiratory rate (< 12/min). Since magnesium is excreted from the body through the renal system, hourly urine output should be assessed.

What is the priority nursing goal in helping a client during a complicated labor? a. Ensure that the client knows what to expect. b. Prevent fear and anxiety. c. Establish a trusting relationship. d. Prevent invasion of privacy.

c. Establish a trusting relationship. Explanation: Establishing a trusting relationship with the client and her family is a priority. A trusting relationship increases the likelihood of cooperation and compliance during a crisis. In an emergency situation such as a complicated labor, the nurse might have little time to ensure that the client knows what to expect. In an emergency situation, such as a complicated labor, the nurse might have little time to ensure that the client's privacy is always protected optimally. While this is an appropriate goal, it is not always possible to prevent fear and anxiety.

The nurse should encourage the pregnant client not to push during vaginal delivery of a breech infant to avoid which of the following? a. Prolapsed cord b. Fetal distress c. Fetal head entrapment d. Cervical lacerations

c. Fetal head entrapment Explanation: Prolapsed cord is a risk inherent with breech delivery whether the woman pushes or not. Fetal distress is a risk inherent with breech delivery whether the woman pushes or not. Molding of the fetal head does not occur during labor in the breech presentation. The fetal body can pass through an incompletely dilated cervix, leaving the larger, firmer fetal head entrapped. The woman might feel a strong urge to push before complete dilatation due to pressure from the fetal body, increasing the risk of head entrapment. Cervical lacerations most often occur at the time of delivery from the application of forceps or manipulation of the fetus to deliver the after-coming head.

The nurse should suspect cephalopelvic disproportion (CPD) after noting documentation of which data for a laboring client? a. Fetal shoulders are too large to pass through the bony pelvis. b. Pelvic outlet is less than 9 cm. c. Fetal head is too large to pass through the bony pelvis. d. Midpelvis is contracted.

c. Fetal head is too large to pass through the bony pelvis. Explanation: A pelvic outlet less than 9 cm refers to a smaller-than-normal pelvis, but does not take into account the fetal head size. A contracted midpelvis refers to a smaller-than-normal pelvis, but does not take into account the fetal head size. Fetal shoulders that are too large to pass through the bony pelvis refers to shoulder dystocia. CPD means that the fetal head is too large to pass through the bony pelvis.

The nurse is assisting in the delivery of a client whose infant has shoulder dystocia. How should the nurse have the client move to perform McRoberts maneuver to assist with delivery? a. Assume a side-lying position for delivery b. Place her legs in stirrups c. Flex the thighs against the abdomen d. Sit upright for delivery

c. Flex the thighs against the abdomen Explanation: Flexing the thighs against the abdomen (McRoberts maneuver) increases the pelvic angle from symphysis pubis to sacrum, and facilitates delivery by making the bony pelvis less restrictive. Placing the legs in stirrups is not sufficient to make the bony pelvis less restrictive. Assuming a side-lying position will not make the bony pelvis less restrictive. Sitting up for delivery will not make the bony pelvis less restrictive.

A client at 10 weeks' gestation who has recently emigrated from Japan comes to the prenatal clinic because she is having some dark brown vaginal spotting, and is experiencing severe nausea and vomiting. The nurse interprets that these symptoms are compatible with which condition? a. Pregnancy-induced psychosis b .Hyperemesis gravidarum c. Gestational trophoblastic disease d. Placenta previa

c. Gestational trophoblastic disease Explanation: The client has three risk factors of molar pregnancy: Japanese background, brownish, "prune juice" vaginal bleeding, and the severe nausea and vomiting associated with excessive hCG found in trophoblastic disease. The client has only one symptom of hyperemesis. Placenta previa presents with bright red bleeding. There is no information suggestive of psychosis.

The nurse is especially interested in which laboratory test, which provides the nurse with the best information about ongoing control of type 1 diabetes mellitus in a pregnant adolescent? a. Post-prandial test b. Oral glucose tolerance test (OGTT) c. Glycosylated hemoglobin (H. A1c) d. Fasting blood glucose

c. Glycosylated hemoglobin (H. A1c) Explanation: A fasting blood glucose indicates current blood glucose level only. The glycosylated hemoglobin (H. A1c) test provides an indication of what glucose levels have been over the last 4-8 weeks, because glucose attaches to the red blood cells (RBC) and remains there for the residual life of the RBC. Increased blood glucose levels will be reflected in an increased percentage of H. A1c. A OGTT indicates current blood glucose levels only. A post-prandial test indicates current blood glucose levels only.

The nurse explains to a client with premature labor that betamethasone will be administered for which purpose? a. Prevent infection b. Prevent cervical dilatation c. Hasten fetal lung maturity d. Stop uterine contractions

c. Hasten fetal lung maturity Explanation: Betamethasone does not stop labor. A side effect of betamethasone is increased risk of infection. Corticosteroids such as betamethasone have been shown to enhance fetal lung maturity and prevent respiratory distress. Betamethasone does not stop cervical changes.

The nurse is admitting to the maternity unit a client who is at risk for precipitous birth. Once the admission procedures have been completed, which action by the nurse should take priority? a. Remove a towel from the shelf to support perineum when crowning occurs. b. Avoid rupturing the amniotic membrane at all times. c. Instruct the client to pant or blow during contractions. d. Leaving the client's room to get extra assistance in case of rapid delivery.

c. Instruct the client to pant or blow during contractions. Explanation: When a client is at risk for precipitous (rapid) birth, the nurse should instruct the client to pant or blow to decrease the urge to push during the contractions, which may slow down the speed of delivery. The nurse should be prepared to rupture the amniotic membrane with an amniohook if crowning occurs before the amniotic membrane has ruptured. A sterile towel (not a clean towel) should be used to support the perineum when crowning occurs. The nurse should not leave the client alone; the nurse should call for someone else to request assistance from healthcare providers.

During which procedure should the nurse wear protective goggles in addition to gloves? a. Changing a soaked disposable bed pad b. Starting an intravenous line c. Performing an amniotomy d. Washing dirty instruments

c. Performing an amniotomy Explanation: Changing a soaked disposal pad places the nurse at risk for contamination from skin contact, necessitating the use of gloves. According to universal precautions, the caregiver should wear goggles when contamination from splashing is possible, as when the membranes are artificially ruptured. Washing dirty instruments places the nurse at risk for contamination from skin contact, necessitating the use of gloves.

While performing a vaginal examination, the nurse should suspect a compound presentation if what is palpated? a. A shoulder presentation b. Protrusion of the hand and arm through the cervix during labor c. Presentation of two fetal parts d. Both feet protruding through the introitus

c. Presentation of two fetal parts Explanation: A compound presentation involves two fetal parts. The fetal head and a hand are the most common combination, although hand-and-foot presentation is also possible. This is incorrect unless a head is also presenting, since this could occur with shoulder presentation. A compound presentation involves two fetal parts, while a shoulder presentation could be one. Both feet presenting is called "double footling breech presentation."

Which intervention carried out by the nurse would be most helpful for the client with lower back pain caused by occiput posterior position? a. Administer small amounts of the ordered opioid analgesic IV. b. Provide an ice pack to place over the lower back. c. Provide counterpressure over the sacral area with the palm of the hand. d. Teach the client how to do pelvic rocking.

c. Provide counterpressure over the sacral area with the palm of the hand. Explanation: Opioid analgesics can be transferred across the placenta to the fetus. Counterpressure over the sacral area during contractions is helpful in alleviating the lower back pain without the use of narcotics that can be transferred across the placenta to the fetus. Ice packs have not been shown to be helpful. Pelvic rocking has been helpful for back pain in the antepartum period, but patients in labor seem to benefit more from conscious relaxation during contractions (avoiding movement and tension).

A nulliparous client has not made any progress in cervical dilatation or station since she was 7 cm and 0 station over two hours ago. The nurse interprets that according to the Friedman curve, this client is experiencing which of the following? a. Prolonged deceleration phase b. Arrest of descent c. Secondary arrest of dilatation d. Protracted active phase

c. Secondary arrest of dilatation Explanation: The word prolonged implies slow, and in this case labor has stopped. The word protracted means slow, and in this case labor has stopped. Arrest of descent occurs when the station, rather than cervical dilatation, does not change. Dilatation has stopped (arrested) after considerable progress. Causes can include hypotonic uterine contractions, malposition, or cephalopelvic disproportion.

A client who admits to substance abuse during pregnancy tells the nurse, "I know I am just a really weak person, but I will try to cut down while I'm pregnant." Which response by the nurse would be most therapeutic? a. "I am concerned about you and your baby. What can I do to help you?" b. "I have heard that before. You need to get serious now, or your baby will suffer." c. "I don't believe that you are weak at all. You just need to say no to drugs." d. "That is a very positive plan. Could you tell me more about feeling like a weak person?"

d. "That is a very positive plan. Could you tell me more about feeling like a weak person?" Explanation: "I am concerned about you and your baby. What can I do to help you?" places the emphasis on the nurse instead of the client and is therefore incorrect. "I don't believe that you are weak at all. You just need to say no to drugs." is demeaning and has a negative undertone, and implies the client could do this if she has enough willpower. "I have heard that before. You need to get serious now, or your baby will suffer." is demeaning and negative, although it is true that the fetus could suffer harm from drug use during pregnancy. "That is a very positive plan. Could you tell me more about feeling like a weak person?" acknowledges the client's intent to cut down on substance abuse while seeking additional information about the client's self-concept.

A client asks what trial of labor means. What is the best response by the nurse? a. "You will need to make progress in the next hour, or a cesarean birth will be planned." b. "Even though your pelvis is small, sometimes it is possible to deliver your baby vaginally." c. "A cesarean birth will be done because you already went into labor and have not made much progress." d. "The healthcare provider is giving you more time to make progress in labor before considering cesarean birth."

d. "The healthcare provider is giving you more time to make progress in labor before considering cesarean birth." Explanation: A trial of labor means that the client will be followed closely and given more time to show progress before considering a cesarean birth. Placing a time limit of one hour makes cesarean birth seem inevitable and can increase the client's anxiety. By stating vaginal delivery is sometimes possible, it makes cesarean birth seem inevitable and can increase the client's anxiety. Cesarean birth is incorrect because the client will be allowed to continue laboring as long as some progress is made.

A 20-year-old gravida 2, para 0 at 37 weeks' gestation calls the nurse because she is experiencing contractions every 7-8 minutes. Her first pregnancy ended with a spontaneous abortion at 18 weeks, and the client had a MacDonald cerclage placed early in the current pregnancy. Which instruction by the nurse is most appropriate? a. "You must wait until your contractions are every 5 minutes before going to the hospital." b. "You need to go to the hospital, so we can stop your premature labor this time." c. "Try a warm bath and relaxation techniques to see if the contractions will go away." d. "You should go to the hospital to be evaluated and have the cerclage removed."

d. "You should go to the hospital to be evaluated and have the cerclage removed." Explanation: The cerclage is usually removed at 37 weeks to allow natural labor to begin. The MacDonald cerclage is a purse-string suture that ties the cervix closed. The suture needs to be removed before vaginal delivery is possible.

The nurse encourages limiting the number of vaginal examinations to minimize the client's risk of which of the following? a. Bleeding b. Loss of control c. Cervical lacerations d. Infection

d. Infection Explanation: Vaginal examinations do not increase the risk of cervical lacerations, which occur during birth. Vaginal examinations do not increase the risk of bleeding. Even with strict adherence to aseptic technique, the risk of infection increases with frequent vaginal examinations, especially if membranes are ruptured, or if labor is prolonged. Most authorities recommend keeping the number of vaginal examinations to a minimum for this reason, as well as for client comfort. Vaginal examinations do not increase the risk of loss of control by the mother.

A client experiencing profuse hemorrhage from placenta previa is being prepared for an emergency cesarean birth. The client exhibits signs of hypovolemia. The nurse makes it a priority to place the client in which position? a. Semi-Fowler's b. Trendelenburg c. Knee-chest d. Left lateral

d. Left lateral Explanation: Knee-chest position will not aid circulation and is unlikely to be maintained by a client in shock. The left lateral position facilitates uteroplacental perfusion. Semi-Fowler's position would decrease maternal cerebral perfusion. Trendelenburg puts the weight of the gravid uterus against the maternal lungs.

Which short-term client outcome would be most appropriate for a client admitted to the hospital with hyperemesis gravidarum and unable to tolerate regular food and fluid intake? a. Identifies favorite foods in the diet b. Measures own hourly intake and output (I&O) c. Verbalizes risks to the fetus d. Maintains present weight

d. Maintains present weight Explanation: While I&O are important measurements; they do not need to be done hourly, and this intervention would help evaluate whether a goal of fluid balance is maintained. A short-term outcome of maintaining present weight is appropriate while the client is being stabilized in the hospital. Being able to identify favorite foods is not sufficient to assure adequate nutritional intake. Verbalizing risks of malnutrition to the fetus does nothing to alter the condition.

For the pregnant client whose fetus has a face presentation, which action should the nurse avoid? a. Performing Leopold's maneuver b. Ambulating the client to the bathroom c. Placing the client in a high semi-Fowler's position d. Monitoring of internal fetal heart rate

d. Monitoring of internal fetal heart rate Explanation: Leopold's manuver would not be harmful for a patient with face presentation. Ambulating to the bathroom would not be harmful for a patient with face presentation. High fowlers positon would not be harmful for a patient with face presentation. The spiral (fetal) electrode used for internal monitoring penetrates 2 mm into the presenting part. While this does not create a problem on the fetal scalp, the face should be avoided for cosmetic reasons, and to avoid eye injury.

After the initial care following amniotomy, the nurse should include which assessment every 2 hours? a. Color and consistency of amniotic fluid b. Maternal blood pressure and pulse c. Fetal movement d. Oral temperature

d. Oral temperature Explanation: Maternal blood pressure and pulse are checked more frequently than every 2 hours during active labor. Fetal movements are checked more frequently during active labor. Color and consistency of amniotic fluid are assessed immediately after rupture, and each time the underpad is changed. The risk of infection is increased after rupture of membranes. Therefore, the nurse should assess temperature every 2 hours.

The nurse discovers a loop of the umbilical cord protruding through the vagina when preparing to perform a vaginal examination. What is the most appropriate intervention by the nurse? a. Call the physician immediately. b. Immediately turn the client on her side, and listen to the fetal heart rate. c. Place a moist, clean towel over the cord to prevent drying. d. Perform a vaginal examination, and apply upward digital pressure to the presenting part while having the mother assume a knee-chest position.a.

d. Perform a vaginal examination, and apply upward digital pressure to the presenting part while having the mother assume a knee-chest position. Explanation: The physician should be called immediately after assisting the client. This does nothing to relieve cord occlusion. These actions will do nothing to relieve cord occlusion. Pressure on the cord must be relieved to save the life of the fetus. Applying upward manual pressure to the presenting part and having the mother assume a knee-chest position are appropriate emergency actions, followed by starting oxygen and calling the physician.

The nurse assesses that which maternal conditions in the third trimester would be a contraindication for conducting a contraction stress test? Select all that apply. a. Marginal abruptio placentae b. Pregnancy at 42 weeks' gestation c. Intrauterine growth restriction d. Diabetes mellitus e. Third trimester bleeding

a, e Explanation: Intrauterine growth restriction is an indication for completing a contraction stress test. Diabetes mellitus is an indication for completing a contraction stress test. Post-term pregnancy is an indication for completing a contraction stress test. Contractions elicited during the test could cause increased bleeding if an abruption is present. Contractions elicited during the test could cause increased bleeding if third trimester bleeding is already present.

When providing discharge information to an Rh-negative mother, the nurse evaluates that the client has understood the teaching when she makes which statement? a. "I must have Rh-immune globulin if I ever have a miscarriage." b. "I don't have to be concerned unless my husband is also Rh-negative." c. "The direct Coombs' test will determine if I am sensitized to Rh-positive blood." d. "Since my baby is also Rh-negative, I don't need to worry about it."

a. "I must have Rh-immune globulin if I ever have a miscarriage." Explanation: If the father is also Rh-negative, the fetus will be also, and no problems will occur with this pregnancy. Rh-immune globulin, RhoGAM, must be administered within 72 hours of any event that presents a possibility for the mother to become sensitized to the Rh antigen. This includes pregnancy with an Rh-positive infant, which could be the case in a first-trimester abortion (miscarriage), though the blood type is not usually obtained. The indirect Coombs' test is used to determine maternal Rh sensitization. While this might be correct during this one reproductive event, precautions must be taken during future pregnancies.

A client who experienced an incompetent cervix with a previous pregnancy has had a Shirodkar operation done at 18 weeks in the current pregnancy. The client calls the clinic at 37 weeks' gestation because she is having irregular contractions every 5-7 minutes. Which response by the nurse is most appropriate? a. "You need to go to the hospital to have the cerclage removed before your baby is born." b. "You should wait, and come in when the contractions are closer and harder." c. "You sound like you are worried about this baby. It must be frightening for you." d. "You will need to have a cesarean birth with the Shirodkar cerclage in place."

a. "You need to go to the hospital to have the cerclage removed before your baby is born." Explanation: The Shirodkar operation is closure of the cervix with suture material to prevent preterm dilatation. When labor ensues, the suture must be cut so the fetus can pass through the birth canal. Waiting for harder contractions will increase the likelihood of cervical damage from the suture. This response does not address the client's risk, which is the priority. Clients who expect to have several future pregnancies may be delivered by cesarean to avoid repeated cerclage, but there is no necessity to this option.

A client who has experienced a complete spontaneous abortion expresses her anger at the physician and the nurses for not doing enough to save her pregnancy. How should the nurse evaluate this behavior? a. A common grief response b. Maladaptive coping c. Displaced marital strife d. Ineffective social skills

a. A common grief response Explanation: Feelings of anger are commonly experienced during the grieving process. The client who has had a spontaneous abortion is grieving the loss of her imagined child, and should receive supportive care. Feelings of anger are commonly experienced during the grieving process. There is no data to support that this is displaced marital strife. Feelings of anger are commonly experienced during the grieving process. There is no data to support that the client has ineffective social skills. Feelings of anger are commonly experienced during the grieving process. It is incorrect to assume that the client is experiencing maladaptive coping.

A multiparous client who has been in labor for almost three hours suddenly announces that the baby is coming. The nurse sees the infant crowning. Which intervention should the nurse perform first? a. Ask the woman to pant while preparing to place gentle counterpressure on the infant's head as it is delivered. b. Telephone the physician using the bedside phone. c. Retrieve the precipitous delivery tray from the nursing station. d. Quickly obtain sterile gloves and a towel.

a. Ask the woman to pant while preparing to place gentle counterpressure on the infant's head as it is delivered. Explanation: Nursing action should be directed toward preventing a rapid and uncontrolled delivery of the infant's head. Directing the client to pant prevents pushing. Delivery is imminent, so there might not be time to obtain sterile gloves or towel. The client should not be left alone, so going to the nursing station to get the precipitous delivery tray is not an option. Delivery is imminent, so there might not be time to contact the physician.

The client is admitted in active labor with a breech presentation. Which sign would indicate to the nurse that there is fetal distress?? a. Fetal heart rate (FHR) of 180 beats/minute b. Meconium-stained amniotic fluid c. Increased FHR variability d. Mild variable decelerations

a. Fetal heart rate (FHR) of 180 beats/minute Explanation: Meconium passage often occurs in breech presentation because of pressure on the presenting part, and is not an indication of fetal distress in this situation. Fetal heart rate greater than 160 beats per minutes is considered fetal tachycardia, an early sign of distress. Mild variable decelerations are not indications of fetal distress, and occur more frequently in breech presentations. Increased FHR variability is not an indication of fetal distress, and occurs more frequently in breech presentations.

A full-term pregnant client is admitted with membranes that ruptured 4 hours ago and occasional mild contractions. The fetus has healthy indicators on external monitoring. What is the priority intervention in the nursing plan of care for this client? a. Monitor vital signs b. Encourage ambulation c. Provide clear liquids d. Promote rest

a. Monitor vital signs Explanation: The client may be on bedrest, not ambulating, following rupture of the membranes. The client with premature ruptured membranes is at risk for developing an infection and should have vital signs, specifically temperature, monitored every two hours. Promoting rest is a slightly lower priority for this client. Providing clear liquids is a slightly lower priority for this client.

A client's contractions have become less frequent and less intense in the past hour. Vaginal examination reveals 6-cm dilatation and 0 station, which is unchanged since the last examination over 2 hours ago. The nurse should take which action at this time? a. Notify the healthcare provider of the last exam. b. Encourage the client to turn on her side and rest. c. Continue to observe for one hour for further progress. d. Prepare for cesarean birth.

a. Notify the healthcare provider of the last exam. Explanation: The nurse should suspect cephalopelvic disproportion CPD because of the lack of progress since the last exam. The healthcare provider might assess the maternal pelvis by CT, MRI, or other means, or could stimulate contractions with oxytocin, opting for a trial of labor (TOL). Continued observation will do nothing to resolve the problem. Encouraging rest while lying on the side will do nothing to resolve the problem. Lack of progress could be caused by inadequate contractions and a vaginal delivery could be possible, so it is too early to anticipate cesarean birth.

The nurse reviews the client's chart for results of which diagnostic test that will best indicate a diagnosis of erythroblastosis fetalis? a. Percutaneous umbilical blood sampling b. Amniocentesis c. Biophysical profile d. Indirect Coombs' test

a. Percutaneous umbilical blood sampling Explanation: Amniocentesis provides information about fetal well-being, but does not directly sample the fetal erythrocytes. A biophysical profile provides information about fetal well-being but does not directly sample the fetal erythrocytes. An indirect Coombs' test provides information about fetal well-being but does not directly sample the fetal erythrocytes. Percutaneous umbilical blood sampling (PUBS) obtains an actual sample of fetal blood for analysis.

A client who had no prenatal care presents to the labor and delivery unit with a moderate amount of vaginal bleeding and severe abdominal pain. Fundal height is 34 centimeters. Contractions are every 1.5 minutes, lasting 60 seconds, and strong, with increasing resting tone. The monitor shows consistent late decelerations. What information from the nursing assessment is most consistent with a risk for placental abruption? a. The client admits to using cocaine. b. The client has had no prenatal care. c. The client is HIV-positive. d. The client is financially disadvantaged.

a. The client admits to using cocaine. Explanation: The risk for placental abruption is increased with cocaine abuse. This data makes the client high risk for complications of pregnancy, but not particularly for abruption. This data makes the client high risk for complications of pregnancy from possible decreased access to care, but not particularly for abruption.

The nurse explains to a pregnant client at 37 weeks' gestation that a Bishop score is being completed to determine which of the following? a. The client's readiness for labor b. Cervical changes in labor c. Progress during induction d. The fetus's readiness for labor

a. The client's readiness for labor Explanation: The Bishop score, an assessment of the mother's physical readiness for labor, takes into account cervical dilatation, effacement, consistency, cervical position, and station before contractions begin. The higher the score, the more likely a client can be successfully induced. The Bishop score does not evaluate the condition of the fetus. The Bishop score does not evaluate progress during labor. The Bishop score does not evaluate cervical changes during labor.

The nurse concludes that deceleration of the fetal heart rate from 130 to 80 beats per minute with contractions, followed by a rapid return to a normal baseline rate, is most likely a client's response to which event? a. Umbilical cord compression b. Fetal head compression c. Severe fetal hypoxia d. Utero-placental insufficiency

a. Umbilical cord compression Explanation: The pattern described is a variable deceleration, which is associated with umbilical cord compression. During variable decelerations, the FHR drops below 90 beats a minute very quickly as fetal blood flow through the umbilical cord is interrupted. FHR returns rapidly to baseline as soon as the cord compression is relieved. FHR patterns associated with fetal head compression (early deceleration) have a shallower appearance, since they do not drop as precipitously. Variable deceleration, unless severe (lasting longer than 60 seconds), does not indicate severe hypoxia. FHR patterns associated with utero-placental insufficiency (late deceleration) have a shallower appearance, since they do not drop as precipitously.

A pregnant client who acknowledges use of crack cocaine during pregnancy asks the nurse not to inform the baby's father about the substance use. Which responses by the nurse would be appropriate? Select all that apply. a. "Have you considered that he deserves to know that the baby may be at risk?" b. "What reaction do you think the baby's father will have?" c. "You must be worried about how he will react to that information." d. "Your baby will probably not survive, so there is no need for him to know." e. "This is your pregnancy and your body, so I'll keep your information private."

b, c Explanation: Addressing the client's worry is a therapeutic response to the client's concerns. Stating to keep the information private is nontherapeutic because it does not explore the client's concern. Stating the baby is not likely to survive is inaccurate. Asking whether the father deserves to know is judgmental. Asking about the father's reaction gathers more data and also provides an opportunity to assess possible client safety concerns.

Which of the following factors found in a prenatal client's history would place her at increased risk for ectopic pregnancy?Select all that apply. a. Android pelvis b. Endometriosis c. Pelvic inflammatory disease d. Previous cesarean delivery e. Late menarche

b, c Explanation: An android pelvis would not interfere with movement of the ovum. Previous endometriosis can cause scar tissue formation that could block the normal passage of a fertilized ovum through the fallopian tube. Late menarche would not interfere with movement of the ovum. Previous cesarean delivery would not interfere with movement of the ovum. Pelvic inflammatory disease can cause scar tissue formation that could block the normal passage of a fertilized ovum through the fallopian tube.

Following amniotomy, the nurse would implement which high priority nursing actions?Select all that apply. a. Position the mother in lithotomy position for delivery. b. Listen to fetal heart tones. c. Observe the color and consistency of the amniotic fluid. d. Take vital signs every four hours to monitor for infection. e. Place a clean underpad on the bed.

b, c Explanation: Priority nursing interventions after an amniotomy are: Observe the color and consistency of the amniotic fluid and Listen to fetal heart tones—these are the correct answers. Place a clean under pad on the bed assists in comfort, but is not a priority-should not be a correct answer The mother should not be placed in the lithotomy position for delivery after an amniotomy Vital signs should be taken every 1-2 hours to assess for changes in temperature which could indicated infection

A client with class II heart disease is being seen for her first prenatal visit. Which teaching point would the nurse stress for this client? Select all that apply. a. Avoid all over-the-counter (OTC) medications during pregnancy. b. It's important to take prenatal vitamins and iron as prescribed. c. Adequate nutrition to prevent anemia and avoid excessive weight gain d. The client's fetus will probably have a similar congenital heart defect. e. Regular exercise will help increase cardiac capacity during pregnancy.

b, c Explanation: • The client should discuss medications with her caregiver, but she may be allowed to take acetaminophen or a few other OTC medications. • Exercise increases the cardiac workload and should be avoided by clients with heart disease. • Prenatal vitamins and iron promote health of the mother and fetus. • There is a 2-4% chance that the baby will inherit a congenital defect. • Adequate nutrition is helpful in preventing anemia, which could increase the cardiac workload.

After teaching the pregnant client and her husband about premature labor, the nurse evaluates the instruction was effective when the client states which statement?Select all that apply. a. "I will call the office if I notice excessive fetal movement." b. "I will call the office if I have back pain that does not go away." c. "I don't need to worry about occasional irregular contractions." d. "I will call the office for abdominal cramps or pressure that don't stop after I drink 3-4 cups of liquid and rest for an hour." e. "I will lie down and rest awhile if I notice watery vaginal discharge."

b, c, d Explanation: Excessive fetal movement can sometimes indicate fetal distress, but is not a sign of premature labor. Signs of premature labor can include persistent back pain. The client should be instructed to empty her bladder, lie down on her side, and drink 3-4 cups of water. If symptoms do not disappear within an hour, the healthcare provider should be notified. Watery vaginal discharge should be reported sooner rather than later after lying down and resting because the fluid could be amniotic fluid. Signs of premature labor can include abdominal cramping and pressure, or persistent back pain. The client should be instructed to empty her bladder, lie down on her side, and drink 3-4 cups of water. If symptoms do not disappear within an hour, the healthcare provider should be notified. Occasional irregular contractions are called Braxton Hicks contractions and are normal during pregnancy.

The client is scheduled to have an amniocentesis for assessment of lung maturity. She seems upset, and says that she doesn't understand how this test could tell if a baby's lungs are mature. What is the best response by the nurse? a. "The amount of bilirubin in amniotic fluid increases as the lungs mature. We check for yellow colored fluid to assess lung maturity." b. "A chemical called lecithin is made by the fetal lungs and increases as pregnancy continues. It flows into amniotic fluid, where we can measure it." c. "Please try not to worry about that. Your healthcare provider knows the procedure well." d. "The fluid changes color as the fetal lungs mature. We look at the color to determine lung maturity."

b. "A chemical called lecithin is made by the fetal lungs and increases as pregnancy continues. It flows into amniotic fluid, where we can measure it." Explanation: To ask a client not to worry or state the healthcare provider knows the procedure well does not provide information to the client. The color of the amniotic fluid is not useful in determining lung maturity. The amount of lecithin increases as the fetal lungs mature. The ratio of lecithin to sphingomyelin is used to assess lung maturity. Bilirubin levels in amniotic fluid do not determine lung maturity.

The nurse conducts client teaching with a pregnant client who has placenta previa and who states her religious beliefs prohibit receiving blood or blood products. The nurse evaluates that the teaching has been effective if the client makes which statement? a. "I might have to sign out of the hospital against medical advice (AMA)." b. "I will meet with the dietician to increase the amount of iron in my diet." c. "A judge will force me to accept a transfusion if I really need it." d. "There is little chance that I will bleed heavily during this pregnancy."

b. "I will meet with the dietician to increase the amount of iron in my diet." Explanation:A judge will not force a transfusion. The client will not need to sign out AMA to avoid receiving a transfusion, even if one is indicated. The client is likely to lose some blood with a placenta previa. Increasing iron in her diet is a positive response that does not interfere with her religious beliefs. It is not possible to predict that amount of bleeding that could be experienced by a specific client with placenta previa.

A pregnant client visits the prenatal clinic for a routine visit during the second trimester of pregnancy. Which assessment findings should lead the nurse to suspect development of a central abruptio placentae? a. Leakage of amniotic fluid b. Abdominal pain c. New onset hypertension d. Painless vaginal bleeding

b. Abdominal pain Explanation: Painless vaginal bleeding would occur with placenta previa; there is no bleeding in a central abruption, in which blood is trapped between the placenta and uterine wall. Abdominal pain or uterine tenderness is a classic sign of a central placental abruption, which is characterized by separation of placenta from the uterine wall. Premature rupture of membranes is associated with leakage of amniotic fluid. New onset of hypertension should be further assessed to determine development of preeclampsia.

The nurse locates fetal heart tones in the right upper quadrant of the abdomen. This finding should cause suspicion that the fetus is in what presentation? a. Shoulder b. Breech c. Occiput posterior d. Occiput transverse

b. Breech Explanation: The term occiput posterior refers to a head position (fetal malposition) rather than a fetal malpresentation. The term occiput transverse refers to a head position (fetal malposition) rather than a fetal malpresentation. Fetal heart tones are heard loudest over the fetal back. In breech presentation, this tends to be above the umbilicus. Fetal heart tones are heard just below the midline of the umbilicus in shoulder presentation or transverse lie.

A client who has experienced a spontaneous abortion at 8 weeks asks why this happened. What would the nurse include in a response to address the most common cause of "miscarriage?" a. Excessive activity b. Chromosome abnormalities c. Substance abuse d. Environmental teratogens

b. Chromosome abnormalities Explanation: The majority of early abortions are related to abnormal chromosomes. The client might fear that she has caused the loss, and should be provided with accurate information. The majority of early abortions are not related to environmental teratogens. The majority of early abortions are not related to excessive activity. The majority of early abortions are not related to substance abuse.

The onset of late decelerations on the fetal monitor should lead the nurse to suspect which condition? a. Cord compression b. Decreased uteroplacental blood flow c. Head compression d. Close uterine contractions

b. Decreased uteroplacental blood flow Explanation: Head compression causes early decelerations Cord compression causes variable decelerations. Uteroplacental insufficiency (UPI) is believed to be the cause of late decelerations. The insufficiency or decreased uteroplacental blood flow leads to fetal hypoxia. Several factors including maternal hypotension, anemia, vasoconstriction, uterine tetany, and dehydration can be primary causes of UPI. Close uterine contractions is incorrect because it might not lead to UPI and eventual late deceleration.

The initial laboratory results for a primigravida indicate a hemoglobin of 12 grams/dL, hematocrit of 36%, and a blood group and type of A, Rh-negative. What would be the priority nursing action to promote a healthy pregnancy for this client and her fetus? a. Suggest adding an iron supplement to the prenatal vitamins. b. Determine the blood type of the father. c. Provide information on weight gain during pregnancy. d. Encourage the client to eat more dark green, leafy vegetables.

b. Determine the blood type of the father. Explanation: The Rh-negative client whose partner is Rh-positive could carry an Rh-positive fetus, and would be at risk for Rh-sensitization, which could create risks for future pregnancies. The father of the baby needs to have his blood type assessed. The client is not anemic based on these hemoglobin and hematocrit values. There is no relationship between the lab values and the client's weight in this scenario.

The nurse would question an order for which laboratory test, which is inappropriate to test the current condition of a newborn of an HIV-positive mother? a. Bilirubin level b. ELISA testing c. Blood glucose level d. Hematocrit

b. ELISA testing Explanation: A bilirubin level will give information about the infant's current condition. A blood glucose level will give information about the infant's current condition. The infant of an HIV-positive mother will test positive on an ELISA test for the human immunodeficieny virus because maternal antibodies cross the placenta during pregnancy. This does not indicate that the newborn has HIV. The diagnosis using the ELISA test for the baby is not made until around 15 months, when maternal antibodies are degraded and the infant forms antibodies to HIV if infected. Hematocrit will give information about the infant's current condition.

The client in labor says she was told she is having hypertonic uterine contractions but does not understand how these could harm the baby. How would the nurse explain the relationship between hypertonic contractions and risk of fetal distress? a. Placental separation can occur, which can be harmful to both mother and fetus. b. Increased uterine tone and frequent contractions interfere with blood flow to fetus through the uterine arteries. c. Maternal exhaustion occurs, producing a build-up of lactic acid. d. Umbilical cord compression occurs, decreasing oxygen supply to the fetus.

b. Increased uterine tone and frequent contractions interfere with blood flow to fetus through the uterine arteries. Explanation: While maternal exhaustion and lactic acid accumulation can occur over time, they do not immediately threaten fetal well-being. The incidence of umbilical cord compression is not increased. Frequent contractions and increased uterine muscle tone impede the blood flow through uterine arteries to the placenta. Hypertonic contractions are not necessarily associated with placental separation.

When caring for a client with pre-eclampsia, which laboratory result should the nurse report to the physician immediately? a. Hemoglobin 11 grams/dL b. Platelets 50,000/mm3 c. Creatinine 0.3 mg/dL d. Fasting blood glucose 65 mg/dL

b. Platelets 50,000/mm3 Explanation: Creatinine of 0.3 mg/dl is a normal value during pregnancy. Fasting glucose of 65mg/dl is a normal value during pregnancy. Hemoglobin of 11 grams/dl is a normal value during pregnancy. The normal platelet value is 150,000-450,000/mm3. The pre-eclamptic client is at risk to develop the potentially fatal HELLP syndrome, with low platelets as one of the defining factors.

During augmentation of labor with intravenous oxytocin (Pitocin), a multiparous client becomes pale and diaphoretic, and complains of severe lower abdominal pain with a tearing sensation. Fetal distress is noted on the monitor. The nurse should suspect which complication? a. Precipitate labor b. Rupture of the uterus c. Uterine prolapse d. Amniotic fluid embolus

b. Rupture of the uterus Explanation: Symptoms of precipitate labor do not include pallor, diaphoresis, or fetal distress. Amniotic fluid embolus is frequently associated with cardiac and respiratory distress. Although rupture of the uterus is rare, there is an increased risk for multiparas and clients undergoing induction or augmentation of labor. Early signs include pain and a tearing sensation, signs of shock, and fetal distress. Blood loss is usually severe, but might not be visible. Symptoms of uterine prolapse do not include pallor, diaphoresis, or fetal distress.

A client is being discharged from the hospital after evacuation of a molar pregnancy. The nurse recognizes that additional discharge teaching is required when the client makes which statement? a. "I am so sad that I lost this baby." b. "I may need to have chemotherapy after this." c. "I will need to see the doctor yearly for follow-up." d. "I will use contraception for the next year."

c. "I will need to see the doctor yearly for follow-up." Explanation: Expressions of sadness are appropriate for any pregnancy loss, even if no fetus developed. Chemotherapy is a possibility for this client. The client requires frequent monitoring to rule out development of malignancy after experiencing trophoblastic gestational disease. Weekly hCG measurements are done until normal levels are recorded for three weeks. The client should use contraception for at least one year during the follow-up care.

A prenatal client at 14 weeks' gestation reports continuous nausea and vomiting, and a severe headache. The blood pressure is elevated and fundal height is 21 centimeters. Which diagnostic test does the nurse anticipate will be prescribed to confirm a hydatidiform mole? a. Biophysical profile b. Maternal serum alpha-fetoprotein c. Human chorionic gonadotropin d. Sonography

d. Sonography

A client with a known placenta previa is admitted at 30 weeks gestation with painless vaginal bleeding. The nurse weighs the client's peripads to monitor blood loss. After noting an increased weight of 50 grams, the nurse would document that this equals approximately ___ mL blood loss.

50 mL Explanation: One mL of blood weighs approximately 1 gram. Thus, if the client's blood loss was equal to 50 grams of weight, it would be the equivalent of 50 mL.

The nurse interprets that a postpartum client has early postpartum hemorrhage if the amount of vaginal bleeding in the first 24 hours post-delivery exceeds mL? Provide a numeric answer. ___mL/24 hr.

500 mL Explanation: The traditional definition of early postpartum hemorrhage after a vaginal birth is greater than 500 mL in 24 hours.

If the nurse suspects a uterine infection in the postpartum client, the nurse should make which priority assessment? a. The abdomen for distention b. Episiotomy site c. Odor of the lochia d. Pulse and blood pressure

c. Odor of the lochia Explanation: The vital signs might be affected by an infection, but that is not definitive enough to suspect a uterine infection. An abnormal odor of the lochia indicates infection in the uterus. Inspection of the episiotomy site would not provide information regarding a uterine infection. A distended abdomen usually indicates a problem with gas, perhaps a paralytic ileus.

A 37-year-old gravida 1 at 38 weeks' gestation is scheduled for an amniocentesis. After learning the client was diagnosed with diabetes at age 17, the nurse concludes that the procedure is most likely being done to assess for what potential problem? a. Neural tube defects b. Lung maturity c. Effects of TORCH syndrome d. Down syndrome

b. Lung maturity Explanation: Amniocentesis for genetic testing is usually done early in the second trimester. Which tests for fetal abnormalities neural tube defects, TORCH syndrome and Down syndrome. Amniocentesis for a client with diabetes mellitus at 38 weeks' gestation is probably being done to assess lung maturity in anticipation of delivery.

A nurse is monitoring a client receiving intravenous oxytocin (Pitocin) to induce labor, and identifies hypertonic uterine contractions. List in order of priority the actions the nurse should take. 1. Reposition the client. 2. Stop the oxytocin (Pitocin). 3. Check the client's blood pressure. 4. Administer oxygen by face mask at 8-10 L/min. 5. Perform a vaginal examination.

2, 1, 4, 5, 3 Explanation: Uterine hyperactivity decreases the oxygen supply to the fetus. The priority of the nurse is to reduce uterine activity by stopping the oxytocin (Pitocin). Second the nurse acts to increase fetal oxygenation by repositioning the client to the side, left side-lying preferred, to improve uteroplacental blood flow. Third, the nurse then acts to increase fetal oxygenation by administering oxygen by face mask to the mother (this is done after repositioning because oxygen without blood flow is not effective). Fourth, the nurse would then perform a vaginal examination to determine labor progress, and check for a prolapsed cord. Fifth, the nurse would assess the blood pressure for hypotension or hypertension after corrective actions are taken and fetal safety is assessed.

A client with severe pre-eclampsia has a physician's order that reads, "magnesium sulfate 4 grams loading dose to be administered over 20 minutes, then 2 grams/hour." The nurse mixes 20 grams of 10% magnesium sulfate in 1000 mL of Ringers lactate per agency protocol. Using a mini drip IV set, the nurse sets the IV pump to deliver the loading dose at ____ milliliters/hour?

600 mL/hr Explanation: The mixed concentration of magnesium sulfate is 2 grams in 100 mL of fluid. The client should receive 200 mL (4 grams) over 20 minutes, so the pump must be set to deliver 600 mL over 60 minutes.

The postpartum nurse is caring for a client with a pulmonary embolism. The nurse monitors the client for which symptoms of complications? Select all that apply a. Dyspnea b. Diaphoresis c. Sudden high fever d. Sudden onset of chills e. Confusion

a, b, e Explanation: • Confusion can occur because of decreased oxygenation to the brain resulting from loss of adequate gas exchange in the affected area of the lung.• The client would not experience fever; this is more indicative of infection.• Symptoms of pulmonary embolus include sudden onset of dyspnea, chest pain, anxiety, diaphoresis, elevated pulse, and hypotension.• Symptoms of pulmonary embolus include sudden onset of dyspnea, chest pain, anxiety, diaphoresis, elevated pulse, and hypotension• The client would not experience chills; this is more indicative of infection.

The clinic nurse working with women during the postpartum period would interpret that which behaviors exhibited by a client are typical during this time? Select all that apply. a. The mother talks to the newborn and looks often at the newborn's face. b. The mother experiences feelings of depression as she assumes responsibility for her new baby. c. The mother does not sleep or eat well, but tries to take care of herself. d. The mother is receptive to learning about her baby. e The mother does not take care of herself, but attends well to her infant.

a, d Explanation: Feelings of depression indicate potential psychiatric problems and requires additional investigation. Lack of self care indicates potential psychiatric problems and requires additional investigation. Typical behavior during the postpartum period includes accepting responsibility for infant care. An inability to eat or sleep well requires investigation as to the cause, as both are especially important during the postpartum period. Typical behavior during the postpartum period includes activities that demonstrate maternal-newborn bonding.

The nurse explains to a breastfeeding client that which of the following is generally helpful in preventing mastitis? Select all that apply. a. Frequent assessment of the condition of the nipples, to prevent cracking and bleeding b. Decreased frequency in nursing, so the infant will be hungrier at each feeding c. Decreased nursing time, to prevent sore nipples d. Prophylactic antibiotics for all nursing mothers e. Prenatal instruction on proper breastfeeding techniques

a, e Explanation: • Decreasing nursing time can lead to stasis of milk and clogged ducts, which contribute to the development of mastitis.• Waiting too long between feedings can lead to stasis of milk and clogged ducts, which contribute to the development of mastitis.• Routine antibiotics are not given to prevent mastitis. Clients can develop bacteria that are antibiotic-resistant.• Cracked and bleeding nipples provide an entrance for bacteria. Therefore, frequently checking the nipples for cracking will help to prevent mastitis.• Adequate instruction in proper breastfeeding techniques will help prevent mastitis.

A woman who delivered three weeks ago calls the postpartum unit with breastfeeding questions. She wants to know if it is all right to continue to breastfeed while she has the flu. She states that she feels achy all over, has been having chills, and her temperature is 103°F. What question is important for the nurse to ask? a. "Do you have any reddened areas or tenderness on your breasts, or unusual breast discharge?" b. "Do you have any swelling in your legs or visual disturbances?" c. "Have you been sleeping well?" d. "What does your lochia look like now?"

a. "Do you have any reddened areas or tenderness on your breasts, or unusual breast discharge?" Explanation: Sleep disturbances are not associated with mastitis, which is consistent with the symptoms reported by the client. Lochia is not associated with mastitis, which is consistent with the symptoms reported by the client. Mastitis most frequently occurs 2-4 weeks after delivery with initial flulike symptoms plus breast tenderness and redness. The client might be describing symptoms of a breast infection. Edema and visual disturbances are not associated with mastitis, which is consistent with the symptoms reported by the client.

Which of the following statements would the nurse include in educating a client with mastitis? a. "Nurse your baby frequently to prevent stasis of milk and potential further complications." b. "You can take any kind of over-the-counter analgesics, since medications do not go into breast milk." c. "You should give the baby formula until you are better." d. "You can stop the antibiotics when you feel better."

a. "Nurse your baby frequently to prevent stasis of milk and potential further complications." Explanation: The client take all the prescribed medication. The client can continue to breastfeed, since the milk is not infected. The client ask her physician about recommending an analgesic. The client empty her breasts frequently, either through nursing the baby or through pumping her breasts. This will prevent stasis of the milk and further clogged ducts, which could cause further complications and development of an abscess.

The nurse determines that the client who is at greatest risk for postpartum hemorrhage is the one who delivered which infant? a. A 2722-gram (6-lb) infant after a 2-hour labor b. A 3261-gram (7-lb, 3-oz) infant after a 9-hour labor c. A 2608-gram (5-lb, 12-oz) infant d. A 3574-gram (7-lb, 14-oz) infant after a 12-hour labor

a. A 2722-gram (6-lb) infant after a 2-hour labor Explanation: A 2608-gram (5-lb, 12-oz) infant is of normal size while delivery of a large infant is a predisposing factor for postpartum hemorrhage. A rapid (precipitous) labor and delivery can cause exhaustion of the uterine muscle and prevent contraction of the uterus after delivery, which controls the amount of bleeding. A labor of 9 hours with birth of an infant of normal size does not increase risk of postpartum hemorrhage.the amount of bleeding. A labor of 12 hours with birth of an infant of normal size does not increase risk of postpartum hemorrhage.

The postpartum nurse who is reviewing the client assignment determines that which client is at greatest risk for early postpartum hemorrhage? a. A client with uterine atony b. A client who is 17 years old c. A client with endometritis d. A client with an infant weighing 2468-gram (5-lb, 7-oz)

a. A client with uterine atony Explanation: Infants weighing between 2268 and 3175 grams (5-7 lb) would not overdistend the uterus and thus not cause increased risk of postpartum hemorrhage. The client's age does not increase the incidence of postpartum hemorrhage. Endometritis could cause late postpartum hemorrhage, not early postpartum hemorrhage. Uterine atony accounts for 80-90% of all early (within first 24 hours) hemorrhage.

Which nursing measure would be appropriate for the nurse to implement to prevent thrombophlebitis in the immediate recovery period following a cesarean birth? a. Assist the client in performing leg exercises every two hours. b. Ambulate the client as soon as the anesthesia wears off. c. Limit fluid intake for the first 24 hours. d. Place a rolled blanket underneath the client's knees.

a. Assist the client in performing leg exercises every two hours. Explanation: This increases the risk for thrombophlebitis by interrupting venous return in the area of the knee. Limiting fluid intake increases the risk for thrombophlebitis. Leg exercises promote venous blood flow and prevent venous stasis while the client is still on bedrest. Ambulating the client immediately postanesthesia might not be realistic.

The nurse interprets that which factor in a client's history places the woman at greatest risk for postpartal endometritis? a. Cesarean delivery after 24 hours of labor and failure to progress b. Spontaneous vaginal delivery after 8 hours of labor c. Ruptured membranes for 4 hours prior to delivery d. Use of external fetal monitoring during labor

a. Cesarean delivery after 24 hours of labor and failure to progress Explanation: Factors contributing to postpartum endometritis include the introduction of pathogens with invasive procedures, prolonged labor, and prolonged rupture of membranes. The risk of endometritis is greatest after a cesarean delivery, especially after a long labor and prolonged rupture of membranes. External fetal monitoring is not invasive, and does not increase the client's risk for infection. Rupture of membranes only 4 hours before delivery does not increase the client's risk for infection. Spontaneous vaginal delivery after an 8-hour labor does not increase the client's risk for infection.

A client has been taking methylergonovine maleate for uterine subinvolution but it has not been effective. Which procedure does the clinic nurse anticipate will be ordered to correct the cause of this late-postpartum hemorrhage? a. Dilatation and curettage b. Hysterectomy c. Laparotomy d. Hysterotomy

a. Dilatation and curettage Explanation: Late-postpartum hemorrhage most frequently occurs due to retained placental tissue. Dilatation and curettage is the vaginal procedure of choice to remove retained tissue from the uterus. Laparotomy is an abdominal surgery but is not used to treat this condition.al procedure of choice to remove retained tissue from the uterus. Hysterotomy is an abdominal surgery but is not used to treat this condition.l procedure of choice to remove retained tissue from the uterus.

A postpartum client receiving heparin asks whether she can continue to breastfeed. What is the best response for the nurse to give? a. Heparin will not affect the breastfeeding, and requires no special precautions for the infant. b. She should alternate breastfeeding and bottle-feeding. c. She can continue to breastfeed, but must assess the baby daily for ecchymotic spots. d. She should stop breastfeeding immediately.

a. Heparin will not affect the breastfeeding, and requires no special precautions for the infant. Explanation: A woman can continue to breastfeed while on heparin. The infant does not need to be assessed for ecchymoses. Heparin does not pass to the breast milk. Thus, heparin will not affect breastfeeding and requires no special infant precautions. It is unnecessary to alternate breastfeeding with bottle-feeding.

Which items of clothing worn by a postpartal client could possibly promote a problem for the woman? a. Knee-high stockings b. Pantyhose c. Short athletic socks d. Colored tights

a. Knee-high stockings Explanation: Panty hose stretch and are therefore not restrictive to leg circulation. Short athletic socks are not restrictive to leg circulation. The postpartal woman is prone to develop superficial thrombophlebitis due to increased amounts of clotting factors in the blood during the postpartal period, as well as an increased amount of platelets and increased adhesiveness. Any restrictive clothing on the legs should be avoided, such as the elastic on knee high stockings. Tights do not restrict leg circulation are color is of no relevance.

After the delivery of a large-for-gestational-age infant, the nurse notes a client has bright red blood continuously trickling from the vagina. Her fundus is firm and located in the midline. The nurse concludes that which of the following is the most likely cause of this bleeding? a. Lacerations b. Uterine atony c. Retained fragments of conception d. Hematoma

a. Lacerations Explanation: Suspect lacerations if the client is bleeding, especially continuously, and the fundus is firm. Hematoma may be trapped within tissue without evidence of bleeding. If the cause were uterine atony, the fundus would not be firm. When there are fragments of the placenta or the membranes, the uterus will not contract effectively.

A new mother with mastitis is concerned about breastfeeding while she has an active infection. What explanation should the nurse provide? a. The organisms that cause mastitis are not passed in the milk. b. The infant is protected from infection by immunoglobulins in the breast milk. c. The infant is not susceptible to the organisms that cause mastitis. d. The organisms will be inactivated by gastric acid.

a. The organisms that cause mastitis are not passed in the milk. Explanation: The organisms are localized in breast tissue, and are not excreted in the breast milk.

A postpartal client reports sweating, has a temperature of 99.6°F, and has voided over 2,000 mL since delivery. Nursing actions would include which of the following? Select all that apply. a. Draw a blood culture and sensitivity. b. Offer a fresh, dry gown and bed linens to enhance comfort. c. Isolate the client in a private room. d. Explain to the client that these are normal postpartal changes. e. Notify the physician; the client is showing symptoms of puerperal infection.

b, d Explanation: All of these symptoms are normal findings in the first 24 hours postpartum. The body is beginning to return to the pre-pregnancy state. The client does not require isolation. The body is beginning to return to the prepregnancy state. The nurse can explain to the client that these are normal symptoms, and the reasons for the diaphoresis, frequent urination, and low-grade temperature. Offering comfort measures such as a dry gown and linens will enhance the client's feeling of well-being.

A client has developed disseminated intravascular coagulopathy (DIC) following a placenta previa. Which nursing action is important at this time? Select all that apply. a. Monitor reflexes hourly. b. Frequently monitor her vaginal bleeding. c. Assess Homans' sign hourly. d. Monitor results of D-dimer blood tests. e. Administer antibiotics.

b, d Explanation: Homans' sign is associated with thrombophlebitis, not with DIC. DIC is a disorder of widespread microvascular clotting that can result in bleeding once clotting factors are consumed. Vaginal bleeding can be excessive if a coagulation disorder is present. Antibiotics will not affect a clotting disorder. DIC does not affect a client's reflexes. A D-dimer test monitors fibrinogen level, platelet count, fibrin degradation products, and various coagulation times, all of which are altered during DIC.

The nurse is assigned to a postpartum client diagnosed with a right labial hematoma. What instruction should the nurse plan to include in the client's care at this time? a. A warm pack will be used to increase comfort and to decrease blood loss. b. A cool pack will help to decrease bleeding and reduce the swelling. c. Witch hazel pads will be applied to reduce discomfort. d. She needs to give informed consent for surgery to incise and drain the hematoma.

b. A cool pack will help to decrease bleeding and reduce the swelling. Explanation: A warm pack is incorrect because it will increase engorgement at the site via vasodilation. Witch hazel will not decrease the swelling in the area. Labial hematomas do not necessarily need to be drained; they usually resolve on their own. Applying a cool pack will minimize swelling, bleeding, and discomfort.

The home health nurse is making a home visit to a postpartal client. The nurse would document and report which of the following as a symptom of infection? a. Pinkish lochia b. Abdominal tenderness c. Bradycardia d. Oral temperature of 99.2°F

b. Abdominal tenderness Explanation: Pinkish lochia is normal. Bradycardia would be an unrelated finding. The signs of a postpartal infection would include a temperature of greater than 100.4°F on two successive days after the first 24 postpartal hours; tachycardia; foul-smelling lochia; and pain and tenderness of the abdomen. A low grade temperature might indicate a cold or breast milk coming in.

Which nursing intervention would have the greatest direct effect on reducing postpartum hemorrhage? a. Continuous fundal massage to decrease bleeding and facilitate uterine contraction b. Bladder catheterization to maintain uterine contraction c. Administration of a tocolytic drug d. Trendelenburg position to facilitate cardiac function

b. Bladder catheterization to maintain uterine contraction Explanation: Overly aggressive stimulation of the fundus could cause decreased uterine tone; this is detrimental, because overstimulation of the uterine muscle fibers can contribute to uterine atony. Avoid the Trendelenburg position because it has been reported to interfere with cardiac and respiratory function by increasing pressure on chemoreceptors and decreasing the area for lung expansion. A full bladder can cause uterine atony, and contribute to bleeding. If a client has hemorrhaged, a Foley catheter might also be needed to allow accurate measurement of urine output, which is an indicator for kidney function. A tocolytic agent relaxes the uterus; in this case, an oxytocic drug to contract the uterus would be indicated.

The postpartum nurse would use which therapeutic measure to help prevent a urinary tract infection (UTI) in an assigned client who has just delivered an infant? a. Discourage voiding until the bladder regains the sensation of being full. b. Encourage fluids to 3000 mL per day. c. Encourage the intake of orange, grapefruit, or apple juice. d. Promote bedrest for 12 hours postdelivery.

b. Encourage fluids to 3000 mL per day. Explanation: Bedrest is of no value in preventing UTI, although urinary stasis can actually increase risk. The client should attempt to void every few hours, rather than waiting to regain a sense of a full bladder. Adequate fluid intake (up to 3000 mL/day) prevents urinary stasis, dilutes urine, and flushes out waste products, all of which help to prevent UTI. While intake of juices is healthy, it is the large volume of fluid consumed that aids in flushing out wastes.

For which of the following signs of thrombophlebitis should the nurse instruct the postpartal client to look when at home after discharge from the hospital? a. Muscle soreness in her legs after exercise b. Local tenderness, heat, and swelling c. Varicose veins in her legs d. Bruising

b. Local tenderness, heat, and swelling Explanation: Varicose veins is not a classic sign of thrombophlebitis. Local tenderness, heat and swelling areclassic signs of thrombophlebitis that appear at the site of inflammation. Brusing is not a classic sign of thrombophlebitis.

The nurse determines that fetal distress is occurring after noting which of the following signs? a. Pink-tinged amniotic fluid b. Meconium-stained amniotic fluid c. Acceleration of fetal heart rate with each contraction d. Moderate amount of bloody show

b. Meconium-stained amniotic fluid Explanation: Moderate bloody show often occurs late in labor. Pink-tinged amniotic fluid occurs because of a small amount of blood, usually from the cervix. Meconium passage prior to birth occurs in response to a stressful event for the fetus. Accelerations of FHR are considered a normal response, and do not indicate fetal distress.

A client who previously had an infant by cesarean birth has successfully delivered an infant by vaginal birth. During postpartum recovery, she suddenly reports severe pain in the abdomen and between her scapulae. There is minimal amount of vaginal bleeding. What is the nurse's priority action? a. Maintain the rate of IV fluids. b. Notify the healthcare provider promptly. c. Put the client in Trendelenburg position. d. Continue to assess for uterine atony.

b. Notify the healthcare provider promptly. Explanation: The client may be put in modified Trendelenburg position to manage shock, not Trendelenburg. Uterine atony is not the problem and an action rather than an assessment is required. IV fluids would be increased rather than maintained. A common risk associated with vaginal delivery after cesarean is uterine rupture. Pain in the abdomen and between the scapulae can occur when the uterus ruptures. The hemorrhage is concealed and blood accumulates under the diaphragm, leading to scapular pain. This is an emergency, and requires immediate medical intervention, which is initiated by calling the healthcare provider.

Twenty-four hours after delivery, a postpartal client develops a temperature of 99.8°F, has been voiding small amounts frequently, and reports pain upon urination. The nurse would take which action? a. Notify the nursery that the client might have an infection, and separate the baby from the mother. b. Notify the physician of the symptoms. c. Suspect that the client needs to complain because of stress. d. Explain that some women have these symptoms.

b. Notify the physician of the symptoms. Explanation: The infant does not need to be separated from the mother because of a urinary tract infection. This response conveys the idea that these symptoms are normal. This conclusion is judgmental and inaccurate, and is not consistent with the physiological findings. The client reports symptoms that might indicate a urinary tract infection. Cystitis is not an uncommon infection after delivery. The low-grade temperature, dysuria, and frequent voidings of small amounts are symptoms of cystitis. Several factors place women at risk for postpartal urinary tract infections. These include bladder trauma, stasis of urine caused by hypotonicity of the bladder, and catheterization during labor.

The clinic nurse receives a telephone call from a 7-day postpartum client who states she is having increased vaginal bleeding and asks if it is serious and what could be the cause. The nurse suspects which most common etiology of late-postpartum hemorrhage? a. Disseminated intravascular coagulopathy (DIC) b. Retained placental fragments c. Laceration d. Uterine atony

b. Retained placental fragments Explanation: Uterine atony is a cause of early postpartum hemorrhage. DIC is a cause of early postpartum hemorrhage. Retained placental fragments are a cause of late-postpartum hemorrhage (which occurs anytime after the first 24 hours postdelivery). The retained fragments undergo necrosis, forming fibrin deposits and then polyps, which eventually detach from the myometrium, causing hemorrhage. Lacerations are a cause of early postpartum hemorrhage.

During a home visit, a 10-day postpartum client reports development of a reddened, swollen, and tender breast. What should the nurse include in a response to the client? a. This is normal breast engorgement, and should subside within another week. b. These symptoms suggest an inflammatory or infectious process, and require immediate healthcare provider notification. c. She has to stop breastfeeding immediately until the swelling and redness resolve on their own. d. She should mention it to her healthcare provider at her 2-week check-up, because it will be abnormal if it continues after two weeks.

b. These symptoms suggest an inflammatory or infectious process, and require immediate healthcare provider notification. Explanation: These symptoms are suggestive of mastitis, and require prompt attention by the client's physicianhealthcare provider It is not therapeutic to wait for the symptoms to resolve on their own. These symptoms are not characteristic of normal breast engorgement. Breastfeeding does not have to be stopped if mastitis is present.

To minimize the risk of early-postpartum hemorrhage in a client who just had a cesarean birth, the postanesthesia care nurse should include which measure in the plan of care? Select all that apply. a. Assess abdominal dressing for drainage. b. Maintain an IV rate of 125 mL/hr. c. Monitor the drainage on the client's peri-pad. d. Assess the uterus for firmness every 15 minutes. e. Monitor urinary output.

c, d Explanation: • While maintaining the IV rate helps maintain normal hydration, it will not help to prevent or detect early-postpartum hemorrhage.• Assessing the uterine fundus every 15 minutes helps assure that uterine contraction is taking place. Early detection of a boggy uterus can lead to actions that will prevent hemorrhage.• Assessing the abdominal dressing for drainage is appropriate but will not help to detect early-postpartum hemorrhage.• Monitoring urine output is appropriate for the client but reduced urine output is not a specific indicator of early-postpartum hemorrhage.• Monitoring the drainage on the client's peri-pad will directly detect early postpartum hemorrhage.

The home care nurse is caring for a postpartal client, and suspects the development of a postpartum psychosis. Which findings support the nurse's judgment? Select all that apply. a. The woman is tearful without an identifiable reason. b. The woman is calm and seated during the home visit. c. The client can't remember details of the delivery or when the infant last ate. d. The client reports feeling excessively fatigued. e. The client reports voices telling her the baby is evil and must die.

c, e Explanation: Feeling excessively fatigued could indicate that the client is not getting enough rest with the arrival of the infant or that the client may be experiencing postpartum depression. More data would be needed to differentiate these as causes of fatigue, but fatigue is not consistent with postpartum psychosis.• Postpartum psychosis usually becomes evident within three months of delivery. Delusions and hallucinations are common. The risk for suicide or infanticide is increased by the psychotic woman's distorted thoughts about herself and/or the baby. The psychotic woman would typically display agitation, hyperactivity, and confusion.• Adjustment reaction with depressed mood, commonly known as maternal or baby blues, occurs in 50-70% of women, and is characterized by feelings of fatigue, anxiety, or being overwhelmed by the new maternal role. A key feature is episodic tearfulness without reason that typically occurs within a few days of birth and resolves spontaneously on about the 10th postpartal day.• Being calm and seated would support a conclusion that the client is adjusting to motherhood.

Because postpartum depression occurs in 8-26% of postpartal women, the nurse assesses clients for risk factors for postpartum depression during the prenatal period. Which client would the nurse consider to be at risk for postpartum depression? Select all that apply a. A client who is a married primipara with family support b. A client who is an unmarried primipara with family support. c. A client who is a primipara with a history of depression and lack of a supportive relationship. d. A client who is a primipara with documented ambivalence about her pregnancy in the first trimester. e. A client who is an unmarried primipara living on her own who was consistently ambivalent about maintaining the pregnancy.

c, e Explanation: • Risk factors for postpartum depression include primiparity; ambivalence about maintaining the pregnancy throughout the pregnancy; history of previous depression or bipolar illness; lack of a stable support system; lack of a stable relationship with parents or partner; poor body image; and lack of a supportive relationship with parents, especially her father as a child.• Postpartum blues occur in approximately 50-80% of postpartum women; the blues do not particularly indicate that a woman will develop postpartum depression.• Ambivalence regarding pregnancy is a normal response in the first and into the second trimester, but should be resolved by the third trimester.

Which of the following actions by a lactating client would the nurse support to help the client prevent mastitis? Select all that apply. a. When the client's nipples are sore, offer the infant a bottle. b. Wear a tight, supportive bra. c. Encourage the client to breastfeed her infant frequently. d. Apply vitamin E cream to soften the nipples. e. Instruct the mother in breastfeeding shortly after birth, and review correct techniques often.

c, e Explanation: Mastitis is inflammation of the breast tissue causing the breast to feel painful and swollen. It occurs commonly among nursing mothers when bacteria enter the breast through sore cracked nipples, or as a result of milk left in the breast after a feeding. To prevent mastitis new mothers should be educated on the correct techniques on breastfeeding shortly after the birth and education should be reinforced often. Mothers should be encouraged to breast feed their infants frequently and maintain a feeding schedule. This will prevent breasts from becoming too full of milk. Educate the mother not to offer a bottle if nipples are sore, this may cause nipple confusion which may cause the baby not to latch on to the mother. Go braless as often as possible to avoid added pressure on the milk ducts. Let nipples air dry after feedings and rub with lanolin cream to treat sore nipples

A postpartum client develops a temperature during her postpartum course. Which of the following temperatures indicates the presence of postpartum infection? a. 99.0°F 12 hours after delivery, decreasing after 18 hours b. 100.4°F 24 hours after delivery, remaining until the second postpartum day c. 100.6°F 48 hours after delivery, continuing into the third postpartum day d. 100.2°F 24 hours after delivery, decreasing on the second postpartum day

c. 100.6°F 48 hours after delivery, continuing into the third postpartum day Explanation: It is not abnormal for a postpartum client to run a low-grade fever in the first 24 hours. This can be caused by the body's reaction to labor, dehydration, or a reaction to epidural anesthesia. A temperature elevation greater than 100.4°F on two postpartum days not including the first 24 hours meets the criteria for infection. A temperature elevation greater than 100.4°F on two postpartum days not including the first 24 hours meets the criteria for infection. This criterion is the most common standard in the United States.

The nurse would place high priority on assessing which of the following postpartum clients who would be most likely to develop a hematoma? a. A 40-year-old having her first infant b. A 35-year-old having twins c. A 26-year-old with gestational diabetes who required forceps to deliver her large-for-gestational-age infant d. A 17-year-old who had a small-for-gestational-age infant

c. A 26-year-old with gestational diabetes who required forceps to deliver her large-for-gestational-age infant Explanation: Age does not affect the development of a hematoma. A client with gestational diabetes is more likely to have a large baby that could cause tissue trauma during delivery. The use of forceps during delivery is another risk factor for developing a postpartal hematoma. Twins tend to be smaller in size overall, while a large infant increases risk of tissue trauma during delivery. Age does not affect the development of a hematoma.

The nurse observes that a postpartal client who delivered three hours ago has saturated four peripads with bright red blood during the past hour. Her vital signs are stable. The nurse interprets her bleeding to be which of the following? a. Abnormal, requiring inspection for a hematoma b. Normal, requiring no further action by the nurse c. Abnormal, indicating the need to palpate the uterine fundus d. A normal indication of subinvolution

c. Abnormal, indicating the need to palpate the uterine fundus Explanation: Subinvolution causes the majority of late-postpartal hemorrhages occurring after the first 24 hours following delivery. The client did not report excessive perineal pain or pressure, which would be caused by a hematoma. Blood is retained in the tissue with a hematoma, and is not usually visible on the perineal pad. Heavy bleeding is an abnormal postpartal finding. Early hemorrhage can be caused by uterine atony or by a lacerated cervix. Palpation of the uterine fundus can determine uterine atony. Heavy bleeding is an abnormal postpartal finding.

The postpartum nurse would use which measure that would be most effective in detecting development of thrombophlebitis? a. Asking if the client has pain during leg massage b. Assessing for petechiae on the lower extremities c. Asking if the client has calf pain when getting out of bed d. Monitoring the client's temperature

c. Asking if the client has calf pain when getting out of bed Explanation: Thrombophlebitis may cause a mild temperature elevation, but monitoring temperature is not the most direct or effective measure to assess thrombophlebitis. Calf pain upon dorsiflexion of the foot (such as when getting out of bed) indicates a positive Homans' sign, a sign of thrombophlebitis. The legs (especially the calves) should not be massaged with risk of thrombophlebitis, because doing so could dislodge a potential clot. Petechiae are not a clinical sign of thrombophlebitis.

A client continues to pass large amounts of clots and bright red lochia despite the nurse's attempt to massage the fundus. Upon reexamination, the nurse finds that the client's uterine fundus remains boggy. The nursing actions and oxytocin (Pitocin) do not seem to be helping to keep the fundus firm. What second medication does the nurse anticipate the physician will order to manage uterine atony? a. Magnesium sulfate b. Dinoprostone (Cervidil) c. Carboprost (Prostin 15-M or Hemabate) d. Terbutaline sulfate (Brethine)

c. Carboprost (Prostin 15-M or Hemabate) Explanation: Cervidil is used to ripen the cervix before labor. Terbutaline sulfate is a tocolytic, and could cause further muscle relaxation. Magnesium sulfate is used to decrease contractions or prevent seizures. Oxytocin remains the first-line drug, but the prostaglandins now are more commonly used as the second-line drug, and carboprost is the one that is most commonly used. As many as 68% of clients respond to a single carboprost injection, with 86% responding by the second dose.

A client delivered a 9-pound, 10-ounce infant assisted by forceps. When the nurse performs the second 15-minute assessment, the client reports increasing perineal pain and a lot of pressure. What action should the nurse take first? a. Assess the fundus for firmness. b. Put an ice pack on the client's perineum, reassuring the client that this is normal. c. Check the perineum for a hematoma. d. Call for assistance.

c. Check the perineum for a hematoma. Explanation: An ice pack to the perineum can be used to reduce swelling, but a hematoma is abnormal, and should be reported to the physician. The first action is to perform a perineal or vaginal assessment, not to call for additional help. The fundus should be assessed as a routine measure, but the client's complaints warrant perineal or vaginal assessment. Bleeding into the connective tissue beneath the vulvar skin can cause the formation of vulvar hematomas, which develop as a result of injury to tissues with spontaneous as well as operative deliveries (use of forceps). One of the first signs of a hematoma might be complaint of pressure, pain, or an inability to void.

What would the postpartum nurse expect to document about the client's lochia and location of uterine fundus on the second day after delivery? a. Pinkish-brown lochia with no clots, fundus midline and four fingerbreadths below the umbilicus b. Yellowish-white lochia with no clots, fundus three fingerbreadths below the umbilicus c. Dark red lochia with small clots, fundus midline and two fingerbreadths below the umbilicus d. A large amount of bright red lochia with large clots, fundus midline and at the umbilicus

c. Dark red lochia with small clots, fundus midline and two fingerbreadths below the umbilicus Explanation: Yellowish-white color with no clots explains lochia alba, which does not occur until about 10 days postpartum. The fundus should be midline, two fingerbreadths below the umbilicus, with dark red lochia, which might contain small clots (lochia rubra). Pinkish-brown lochia with no clots describes lochia serosa, which usually occurs between days 4 and 9 of postpartum. A large amount of bright red lochia with large clots describes findings that occur with subinvolution.

The client is a 36-year-old woman, gravida 6, para 6, who delivered a baby girl at 38 weeks' gestation after eight hours of labor. The baby weighed 7 pounds, 14 ounces. The client's vital signs are stable, and her lochia is bright red and heavy, and contains various clots. The largest clot is about half-dollar size. The nurse would consider the client to be at high risk for uterine atony for which reason? a. Client's age b. Size of the baby c. Grandmultiparity d. Length of labor

c. Grandmultiparity Explanation: Women that are parity of 6 or higher (grandmultiparity) are at the greatest risk of uterine atony due to repeated distention of uterine musculature during pregnancy. Labor leads to muscle stretching, diminished tone, and muscle relaxation. The size of the baby is considered appropriate for gestational age, and is not considered to be macrosomic. The length of labor is not considered to be prolonged or precipitous. The client's age is not a factor in uterine atony.

A client is in the immediate postpartal period after delivering a 9-pound, 14-ounce baby. The client is a gravida 6, para 5. The nurse has checked the client every 15 minutes for the last 45 minutes. The client has been stable with a firm fundus and moderate amount of lochia. While beginning the final 15-minute assessment, the nurse notices some new blood stains on the top sheet, and discovers the client lying in a pool of blood that covers the protective bedpad. The fundus is located above the umbilicus and is boggy. What should be the nurse's first action? a. Take the client's blood pressure. b. Put the client on a bedpan in case she needs to empty her bladder. c. Massage the uterus. d. Start an IV.

c. Massage the uterus. Explanation: Measuring blood pressure is an assessment; however, the first action is to massage the uterus to stop or slow down the blood flow. It might be important to allow the client to empty her bladder; however, the first action is to massage the uterus to stop or slow down the blood flow. It might be important to start an IV with oxytocin when ordered; however, the first action is to massage the uterus to stop or slow down the blood flow. Uterine massage is the immediate priority to stop or slow down the blood flow.

Which instruction should the nurse include in the discharge teaching plan to assist the postpartal client to recognize early signs of complications? a. Report any decrease in the amount of brownish-red lochia. b. Palpate the fundus daily to make sure it is soft. c. Notify your health care provider of increased lochia or a return to bright red bleeding. d. Expect to pass clots, which occasionally can be the size of a small orange.

c. Notify your health care provider of increased lochia or a return to bright red bleeding. Explanation: Large clots are not routine and should be recognized as a possible sign of complications. A decrease of the amount of brownish-red lochia is normal. The fundus should be firm. An increase in lochia or a return to bright red bleeding after the lochia has changed to pink indicates a complication.

While performing a postpartum assessment, the nurse notices the client's lochia is very heavy. What should be the nurse's first response? a. Reevaluate in 10 minutes to see if the problem has corrected itself. b. Place the client in modified Trendelenburg position. c. Palpate and massage the uterus. d. Elevate the head of the bed to Fowler's position.

c. Palpate and massage the uterus. Explanation: Excessive bleeding must be evaluated and managed immediately to prevent excessive loss of blood and shock. The nurse should palpate the uterus to determine whether it is boggy, and massage the uterus. Elevating the head of the bed will not address the possible complication of early postpartum hemorrhage. Waiting represents a failure to act and will only cause the client harm. Bleeding should be addressed immediately. A modified Trendelenburg position is the classic shock position, but the nurse should first try measures to reduce bleeding and thus prevent onset of shock.

The nurse learns that the fetal head of a client in labor is in complete extension. Which type of delivery should the nurse anticipate for this client? a. Precipitous labor and delivery b. Short labor with forceps-assisted vaginal delivery c. Prolonged labor and possible cesarean section d. Normal labor and spontaneous vaginal delivery

c. Prolonged labor and possible cesarean section Explanation: The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, particularly the position of the head, present larger diameters to the maternal pelvis, which contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery. Precipitous labor and delivery may be more likely to occur when the fetal head is small and in normal position. Normal labor and spontaneous vaginal delivery are not as likely to occur when the fetal attitude widens the presenting part in the maternal pelvis, such as with complete fetal head extension. Complete extension of the head may make delivery more difficult, so labor would not be expected to be short, although forceps-assisted delivery may be an option

It is most important for the nurse to have which drug readily available when the client is being treated with heparin therapy for thrombophlebitis? a. Calcium gluconate b. Vitamin K c. Protamine sulfate d. Ferrous sulfate

c. Protamine sulfate Explanation: Calcium gluconate raises serum calcium levels. Vitamin K is the antidote for warfarin. Protamine sulfate is the drug used to combat bleeding problems related to heparin overdose. Ferrous sulfate is an iron supplement dose.

A postpartum client develops thrombophlebitis in her right calf and is started on heparin therapy. Which nursing intervention would be most appropriate at this time? Select all that apply. a. Inform the client that she will experience numbness in her leg for several months. b. Encourage the client to ambulate to reduce lower-extremity swelling. c. Encourage the client to take aspirin for leg pain. d. Explain that the client should use a soft toothbrush and only an electric razor. e. Instruct the client to remain on bedrest to reduce the possibility of embolism.

d, e Explanation: • The client should not ambulate because it could lead to pulmonary embolus if the blood clot dislodges.• The client should be started on heparin therapy and therefore should avoid aspirin and nonsteroidal anti-inflammatory drugs that will potentiate the action of heparin.• Bedrest is recommended following a diagnosis of thrombophlebitis, to help prevent development of a pulmonary embolus.• The client should not experience any residual effects in the extremities.• The client receiving full anticoagulant therapy with heparin should be placed on bleeding precautions to reduce the risk of bleeding. These precautions include using a soft toothbrush and electric razor rather than a straight razor.

On the client's third postpartum day, the nurse enters the room and finds the client crying. The client states that she doesn't know why she is crying, and that she can't stop. What is the most appropriate statement for the nurse to make? a. "There is no need to cry, you have a healthy baby." b. "This happens to lots of mothers. In time it will pass." c. "Are you dissatisfied with your care?" d. "Many new mothers have shared with us their same confusion of feelings. Would you like to talk about them?"

d. "Many new mothers have shared with us their same confusion of feelings. Would you like to talk about them?" Explanation: Responding with patronizing answers does nothing to assist the mother to talk about her thoughts and feelings, and could increase her sense of isolation and feelings of inadequacy and despair. Assuming the client is dissatisfied with care fails to assess the client's concerns. Creating an environment where a client and her family can discuss emotional concerns is essential. Sharing time with the new mother to discuss thoughts and feelings is important to clients. Responding with patronizing answers does nothing to assist the mother to talk about her thoughts and feelings, and could increase her sense of isolation and feelings of inadequacy and despair.

A client has just been diagnosed with mastitis. The nurse should place highest priority on teaching the client which of the following? a. Nurse the infant only from the uninvolved breast. b. Tightly bind the breasts with elastic bandages. c. Stop breastfeeding totally to allow the infection to heal. d. Breastfeed frequently to prevent any stasis of milk.

d. Breastfeed frequently to prevent any stasis of milk. Explanation: The client needs to empty her breasts frequently to prevent stasis of milk, which can cause further problems with the mastitis. The infant will not be affected by the infection in the mother's breast; it does not get into the breast milk. Stopping the breastfeeding would do nothing to help with the mastitis. Binding the breasts would do nothing to help with the mastitis.

A client who is at 34 weeks' gestation has been having contractions every 10 minutes. In addition to instructing her to lie down and rest while continuing to time contractions, the nurse should also tell her to do which of the following? a. Take slow, deep breaths with each contraction. b. Refrain from eating or drinking anything. c. Go to the hospital if contractions continue for more than an hour. d. Drink 3-4 cups of water.

d. Drink 3-4 cups of water. Explanation: Hydration has been shown to decrease premature labor contractions. Therefore, drinking water or other noncaffeinated beverages is recommended. Slow deep breaths would only be needed if the contractions were uncomfortable. If contractions continue at 10 minutes apart or less for an hour with rest, the client should call her health care provider.

A newly postpartum client is going into hypovolemic shock as a result of uterine inversion. Which initial order should the nurse expect to implement to restore fluid volume? a. Administer oxygen at 3-4 L/min via nasal cannula. b. Monitor heart rate every 5 minutes. c. Administer an oxytocic drug via IV. d. Increase the IV infusion rate.

d. Increase the IV infusion rate. Explanation: Oxygen would be given to increase perfusion to tissues, but does not restore circulating volume. An oxytocic drug will help to limit further bleeding, but will not restore circulating volume. Monitoring heart rate will not limit the condition because it is an assessment rather than an intervention. Increasing the rate of IV fluids is an effective initial measure necessary to replace lost fluid volume that occurs in uterine inversion caused by hemorrhage. Blood products might also be necessary, but generally take some time to obtain from the blood bank.

The partner of a 4-day postpartum woman calls the nursing unit saying that she is happy one minute and cries the next. He states, "She never was like this before the baby was born." What is the best initial response by the nurse? a. Instruct the partner in signs and symptoms of postpartum psychiatric disorders. b. Advise contacting a psychiatrist immediately; this is the first step in postpartum psychosis. c. Make a suggestion to ignore the mood swings, as they will go away. d. Provide reassurance that this is normal in the postpartum period because of hormonal changes.

d. Provide reassurance that this is normal in the postpartum period because of hormonal changes. Explanation: Telling the partner to ignore the mood swings fails to address the client's concern. In this case, the partner is the client. Before providing further instructions, the nurse should explain that these are signs of postpartum blues, which is a normal process related to hormonal changes. Advising the partner to consult a psychiatrist immediately is an excessive response. Teaching the client about various postpartum psychiatric disorders is unnecessary and excessive.

The nurse notices that a client who just gave birth to her first baby stays in her room, has no visitors, has not taken a shower since delivery, and keeps her back turned to the baby's bassinet when the baby is in the room. What further evaluation should the nurse make? a. Assess the client's vital signs. b. Assess the client for pain. c. Check to see if the client listed a contact person in case of emergency. d. Review the chart to see if the client had anyone with her during labor and what kind of support system she has.

d. Review the chart to see if the client had anyone with her during labor and what kind of support system she has. Explanation: The client's vital signs will not assist the nurse in helping the client with symptoms of depression. The client is demonstrating symptoms of depression. Primiparas without support are at higher risk for postpartum depression. Determining her lack of support systems will help to assess her risk for depression and the need to develop an appropriate plan to deal with this concern. There is no need to determine whether an emergency contact person is identified because the client's physiological status is stable. Identifying pain will not assist the nurse in helping the client with symptoms of depression.

A client with a complete placenta previa is hospitalized on bedrest at 24 weeks' gestation. In preparing the plan of care, what nursing diagnosis takes priority for this client? a. Activity Intolerance related to enforced bedrest b. Ineffective Tissue Perfusion related to placental location c. Anticipatory Grieving related to potential fetal loss d. Imbalanced Nutrition: Greater than Body Requirements related to sedentary lifestyle

b. Ineffective Tissue Perfusion related to placental location Explanation: The priority diagnosis is related to maintaining circulation and oxygenation. The other nursing diagnoses are of lesser importance.

A client with premature rupture of membranes (PROM) at 33 weeks' gestation is to be given betamethasone to increase fetal lung maturity. The nurse checks the client's record to ensure that the client does not have what disorder that could be affected by this drug? a. History of alcohol abuse b. Intrauterine growth restriction (IUGR) c. Diabetes mellitus d. Incompetent cervix

c. Diabetes mellitus Explanation: Glucocorticoids raise the blood glucose and this has implications for diabetic control in a client with diabetes mellitus. A history of alcohol abuse is not a contraindication for giving betamethasone. Incompetent cervix is not a contraindication for giving betamethasone. IUGR is not a contraindication for giving betamethasone.

The nurse can help a client with a fetus in the right occiput posterior (ROP) position by avoiding which of the following actions? a. Assisting her to a knee-chest position b. Positioning her on her left side c. Helping her walk around the room d. Positioning her on her right side

d. Positioning her on her right side Explanation: Walking around the room, knee-chest positon and lying on the left side are all positons which may facilitate gravity to rotate the baby to an anterior positon for vaginal delivery. Positioning on the right side does not facilitate the baby to rotate.