Exam 2 Davis Advantage Questions
A postpartum mother delivered two hours ago and has a history of recurrent urinary tract infections (UTIs). She is very anxious about the risk of UTI after delivery and asks the nurse what she can do to decrease her risk. Which response by the nurse would require further education regarding recommendations to prevent UTI? "If you are unable to get up and walk to the bathroom to void in the next hour, I will need to insert a catheter to empty your bladder." "I will need you to keep track of your urine output with the goal of voiding at least 150 mL." "It is important to be changing your peri pad every 3-4 hours." "I will need you to keep track of your oral intake with the goal of drinking at least 1500 mL each day."
"I will need you to keep track of your oral intake with the goal of drinking at least 1500 mL each day."
Following cesarean delivery, a stable female infant weighing 3,126 grams is placed skin-to-skin with the mother. The client's partner asks why the infant is placed with the mother during the remainder of the surgery. What is the best response from the nurse? "Placing the infant with the mother reduces the need to have another nurse in the crowded operating room." "We can discuss this later, I need to help the surgeon right now." "Infants are less likely to need NICU care when placed skin-to-skin with the mother." "It is important to get a picture immediately after delivery of the infant."
"Infants are less likely to need NICU care when placed skin-to-skin with the mother."
Following a cesarean section a few hours ago, the partner of a client comes out to the nurses' station to report severe itchiness the client is experiencing. The partner voices concern that the client is experiencing an allergic reaction to the morphine given during surgery. How does the nurse respond to the client when entering to the room to assess the itching? "Itchiness, also known as pruritis, is a common reaction to morphine and is not considered an allergy." "Here is some medication to stop the itching." "I will note in your medical record that you have an allergy to morphine." "Let me call the provider and report the itching."
"Itchiness, also known as pruritis, is a common reaction to morphine and is not considered an allergy."
A provider has determined a client needs a cesarean section for cephalopelvic disproportion. The client asks the nurse to explain what cephalopelvic disproportion means. What is the best response by the nurse? "You are needing a c-section due to the baby experiencing stress from labor." "Let's focus on preparing for the surgery." "The baby is too large for your pelvis." "Have you had a recent ultrasound to estimate the baby's weight?"
"The baby is too large for your pelvis."
A woman with Type I diabetes presents for her first prenatal appointment. Which anticipatory guidance would the nurse provide this patient? "Insulin needs will most likely decrease over the course of the pregnancy" "The risk of DKA is highest in the first trimester" "Watch for signs and symptoms of preterm labor" "If your fasting blood glucose is under 95, you don't need to check it again."
"Watch for signs and symptoms of preterm labor"
A patient at 30 weeks gestation was just diagnosed with gestational diabetes. She asks the nurse how the diabetes will affect her baby. Which is the best response from the nurse? "Your baby might have high blood sugar for several days after birth" "Your baby might be larger than expected at birth" "Your baby is at increased risk of congenital anomalies" "If you follow your diet and control your blood sugar, there would not be any problem for the baby."
"Your baby might be larger than expected at birth"
Which bilirubin level in a healthy term or near-term neonate would the nurse determine is concerning, but not critical, at 36 hours after birth? 1 to 3 mg/dL 4 to 5 mg/dL 10 to 14 mg/dL 15 to 20 mg/dL
10 to 14 mg/dL
A woman who is 28 weeks gestation is screened for gestational diabetes. Her 1-hour oral glucose tolerance test (GTT) is elevated at 145 mg/dL. Which is the most appropriate follow-up test to diagnose gestational diabetes?
3 hour glucose tolerance test
Meconium aspiration syndrome is most likely to occur at which gestational age in the newborn? 29 weeks 4 days 42 weeks 2 days 38 weeks 3 days 32 weeks 6 days
42 weeks 2 days
Sally is a 38-year-old G3P1011 at 33 weeks 4 days admitted to antepartum for a placenta previa. She's begun having painless, heavy bleeding, and her vital signs are 100/51 mm Hg, pulse 108, respirations 20, oxygen saturation 94%, temperature 99.8°F. What type of cesarean section will she receive? Scheduled at 35 weeks Urgent, within the next hour Emergent, immediately Nonurgent, sometime soon
Emergent, immediately
A premature neonate with severe hyperbilirubinemia is starting phototherapy. What nursing intervention is the most important? Bank of lights covered with plexiglass Only diaper in place for maximum exposure Feed neonate every 2 to 3 hours Eye patches in place while under lights
Eye patches in place while under lights
A nurse is preparing to assist a new mother with breastfeeding following a cesarean section delivery. Which positions will the nurse recommend to maximize patient comfort while breastfeeding? Select all that apply. Side-lying position Cradle hold C-cup positioning Using a breast pump Football hold
Football hold Side-lying position
Fetal alcohol syndrome (FAS) can cause physical anomalies. What assessment would the nurse identify as consistent with FAS? Heart defects Increased cranial size Amniotic bands Congenital hip dysplasia
Heart defects
The nurse is admitting a 28-week neonate to the NICU. Which assessment would indicate an intraventricular hemorrhage (IVH)? Tachycardia Hypoglycemia Hypotonia Hypertension
Hypotonia
The nurse is planning to assess a neonate born at 25 weeks. Which would be an expected assessment finding? Select all that apply. Hypotonic muscles Creases on feet Skin is pale Lack of lanugo Fused eyelids
Hypotonic muscles Fused eyelids
What assessment does the nurse know indicates a high risk of retinopathy of prematurity (ROP)? Advanced maternal age Oxygenation of 87-94% Intraventricular hemorrhage Use of oxygen blenders
Intraventricular hemorrhage
The nurse is caring for a patient who is undergoing a term gestation pregnancy induction. Which is the nurse aware of regarding the induction of labor? It is achieved by external and internal version techniques. It is always done for medical indications. It is rated for probability of success by a Bishop score. It is only achieved through oxytocin infusion.
It is rated for probability of success by a Bishop score.
The nurse is in the room with a laboring patient who was found to have a prolapsed umbilical cord. The nurse will place the patient in which positions to help relieve pressure on the cord? Select all that apply. High-fowlers Left lateral Knee-chest Squatting Trendelenburg
Knee-chest Trendelenburg
The nurse is caring for a neonate with a grade II Intraventricular Hemorrhage (IVH). Routine nursing care can cause fluctuations in cerebral blood flow. What nursing strategies will decrease the worsening of this condition? Select all that apply. Minimize crying Minimize stimulation Keep HOB at 45 degrees Keep temperature normal Position infant prone
Minimize crying Minimize stimulation Keep temperature normal
When an infant is experiencing neonatal abstinence syndrome, what nursing action can help to minimize symptoms and complications? Minimize stimulation to promote rest Lay the infant on their abdomen to soothe gas pains Make sure they are only wearing a diaper to prevent diaphoresis Play music or the tv loudly to soothe them
Minimize stimulation to promote rest
The nurse is caring for a patient at risk for preterm labor. Which are risk factors for preterm labor? Select all that apply. Multiple gestation History of preterm birth Maternal smoking Maternal age 18-25 Decreased fetal movement
Multiple gestation History of preterm birth Maternal smoking
The nurse is caring for a patient following a precipitous delivery. Which complication would the nurse watch for? Retained placenta Postpartum hemorrhage Hemorrhoids Uterine rupture
Postpartum hemorrhage
An example of a complication that would require an emergent cesarean section is Breech presentation IUGR diagnosis Prolapsed cord Cat I strip with maternal febrile episode
Prolapsed cord
Which of the following is a risk factor for the development of a DVT? Primiparity in an adolescent Sedentary lifestyle Long-distance running Delivering a small for gestational age infant
Sedentary lifestyle
Regarding oxytocin for labor induction, what is the most concerning side effect of oxytocin? FHR baseline change from 140-130 Increased blood pressure Oliguria Tachysystole
Tachysystole
The four Ts that represent the most common causes of a PPH are ___________________.
Tone, tissue, trauma, thrombin disorders
The nurse is teaching parents about home use of the fiberoptic bili blanket. Which statement by the mother indicates effective teaching? "I should dress my baby before wrapping him in the bili blanket." "I should wrap my baby from neck to toe in the bili blanket." "I can unwrap my baby for feedings." "I should keep the bili blanket on 24 hours a day."
"I should keep the bili blanket on 24 hours a day."
While the nurse is preparing a client for an emergency cesarean section, the family voices concern that the client is extremely nervous about the procedure. How does the nurse respond to the client? "Tell me about how you are feeling right now." "We do many c-sections every day, you will be fine." "I am going to insert the foley catheter now." "It is important that you try to calm down for the baby."
"Tell me about how you are feeling right now."
A woman in the second stage of labor has been pushing for 3 hours. The provider is preparing for a vacuum-assisted delivery. Which anticipatory guidance should the nurse give to the patient? "The blades of the forceps will be applied to the fetal head." "The baby may have some bruising and edema of the head." "You will need to push between contractions." "An episiotomy is required for a vacuum delivery."
"The baby may have some bruising and edema of the head."
A mother who has been breastfeeding for three months calls the clinic to speak to the nurse. She reports a fever, unilateral breast swelling, pain and redness. She is worried about continuing to breastfeed. What is the appropriate nursing response? "Pump and discard your breastmilk until you finish your course of prescribed antibiotics." "Massaging the area while you breastfeed will treat the infection." "Your milk is not infected, so you can continue to breastfeed and we will prescribe an antibiotic today." "You need to be more diligent about cleaning your pump supplies."
"Your milk is not infected, so you can continue to breastfeed and we will prescribe an antibiotic today."
Testing for gestational diabetes mellitus usually takes place between _______ and ______ weeks.
24-28 weeks
The obstetric nurse is preparing a client for an epidural. What is the priority nursing intervention prior to this procedure? Monitor FHR Obtain maternal BP Administer IV fluid bolus Assess for prior epidural anesthesia
Administer IV fluid bolus
While assessing a post-operative cesarean section client, the nurse notes a temperature of 102.1?. Prior to calling the provider, what other assessment should the nurse complete to include when reporting the concern? Identify time of last pain medication Assess C section incision Assess lung sounds and inceptive spirometry Assess uterine fundus and lochia
Assess C section incision
A patient in labor is noted to have an occiput posterior presentation. Which complications would the nurse anticipate? Prolapsed cord Facial bruising in neonate Dystocia Shortened second stage
Dystocia
The recovery room nurse is completing a postpartum assessment on a newly delivered patient. Upon assessment, the nurse finds the peripad saturated with lochia, with large, visible clots. What is the priority nursing intervention based on these findings? Document the findings on the medical record. Massage the uterus until firm. Start an IV and give a bolus of oxytocin. Walk the patient to the bathroom.
Massage the uterus until firm.
Infection can contribute to or cause which of the following high-risk pregnancy complications? Select all that apply. Hyperemesis gravidarum Pyelonephritis Ectopic pregnancy Preeclampsia PPROM
PPROM Pyelonephritis Ectopic pregnancy
A gravid woman at 30 weeks gestation presents to the labor and delivery unit reporting painless, bright red vaginal bleeding. Which condition would the nurse suspect? Placental abruption UTI Placenta previa Placenta accreta
Placenta previa
A gravid woman has been admitted with preeclampsia. The nurse knows to watch for signs of potential eclampsia. Which signs or symptoms might indicate impending eclampsia? Select all that apply. Severe headache Clonus Restlessness Epigastric pain DTR +2
Severe headache Clonus Restlessness Epigastric pain
A patient delivered four hours ago after via cesarean section for preeclampsia calls the nurse to the bedside. The patient reports dizziness, diaphoresis and oozing of blood from her current IV site. The nurse determines these findings are consistent with which of the 4 Ts? Tone Tissue Trauma Thrombin
Thrombin
The nurse is assessing a patient who is a G5T5P0A0L5 and delivered vaginally four hours ago. The patient's labor history included a 16 hour oxytocin induction for a macrosomic infant. Assessment findings include a boggy uterus and a completely saturated peri pad with the presence of blood clots. What does the nurse identify as the most likely cause for the increased bleeding? Tone Tissue Trauma Thrombin
Tone
A client is pregnant with her second child following a cesarean section delivery with the first pregnancy for a breech fetal position. The couple plans to have three children total. What option does the nurse discuss as the best one for this couple? Vaginal birth Repeat C section External cephalic version Only having 2 children
Vaginal birth
When are one-third of pregnancies that end up with a high risk complication identified? At the first prenatal visit A year before pregnancy occurs When the complication arises At delivery
When the complication arises
The nurse is teaching a childbirth education class. Which statements regarding induction of labor would be included in the teaching? Select all that apply. Labor induction is used only for medical Prior to using oxytocin for labor induction, the cervix should be favorable. As long as you are over 37 weeks gestation, your doctor may induce you for convenience. The risks of labor induction are the same as the risks with spontaneous labor. You should not have a labor induction if you have active herpes.
You should not have a labor induction if you have active herpes. Prior to using oxytocin for labor induction, the cervix should be favorable.
In order to correctly differentiate high-risk pregnancy complications, the first step should always be ______________. charting any unusual findings relaying vital signs along with signs and symptoms to the provider applying the nursing process and assessing the patient performing appropriate interventions to prevent the condition from worsening
applying the nursing process and assessing the patient
The nurse is teaching a woman about her diagnosis of preeclampsia. Which statement made by the patient indicates the need for further teaching? "I only have mild preeclampsia, so it will not be harmful to me or my baby." "I am at risk of developing heart disease." "I need to report severe headaches or changes in my vision." "I might need to be induced early."
"I only have mild preeclampsia, so it will not be harmful to me or my baby."
The nurse is caring for a patient who was diagnosed with gestational diabetes mellitus (GDM) at 28 weeks of pregnancy. The patient had an uncomplicated vaginal birth 12 hours ago. Which statement made by the patient would require further education? "Breastfeeding my baby will help reduce my risk for developing Type II diabetes." "My diabetes will resolve in the next few weeks, so there is no need for follow up." "I have a much higher risk of developing Type II diabetes now that I have had gestational diabetes." "I need to see a provider for preconception glucose control prior to my next pregnancy."
"My diabetes will resolve in the next few weeks, so there is no need for follow up."
The oncoming nurse is reviewing her assignment for the day, and would like to identify who see first based on acuity. Which woman is at greatest risk for primary postpartum hemorrhage? A G5P4 patient with obesity and undergoing labor induction. A G2P2 patient who delivered a baby vaginally after an 8-hour labor augmented by oxytocin. A G1P1 woman who just delivered via emergency cesarean section for fetal distress. A G2P2 woman delivering vaginally after a cesarean section with her first pregnancy.
A G5P4 patient with obesity and undergoing labor induction.
The nurse is caring for five postpartum patients. Which patients does the nurse recognize as being at an increased risk for postpartum hemorrhage (PPH)? Select all that apply. A patient who delivered vaginally after a two-hour labor A patient who delivered a 3300-gram infant via repeat cesarean A patient who delivered twins A patient with Von Willebrand disease A patient with a history of preeclampsia during her previous pregnancy
A patient who delivered vaginally after a two-hour labor A patient who delivered twins A patient with Von Willebrand disease
While presenting an educational session on childbirth the nurse was asked to discuss risk factors requiring a cesarean section. What should the nurse include in her response? Select all that apply. Advanced maternal age Spontaneous labor onset Breech position Maternal request Multiparity
Advanced maternal age Breech position
Abrupt discontinuation of intrauterine exposure to various substances, including heroin, nicotine, alcohol, cannabis, opiates, cocaine, and methamphetamines puts the neonate at risk for signs and symptoms of neonatal abstinence syndrome (NAS). The withdrawal of what substance can cause symptoms of NAS to start within 4 hours? Cannabis Alcohol Narcotics Barbituates
Alcohol
A gravid patient in labor suddenly has dyspnea, hypotension, frothy sputum, and loss of consciousness. The nurse knows these are signs and symptoms of which obstetrical emergency? Placental abruption Uterine rupture Uterine inversion Amniotic fluid embolism
Amniotic fluid embolism
A nurse is caring for a client following a cesarean section four hours ago that occurred due to arrest of labor. Initially, the client was admitted to the hospital two days ago after experiencing spontaneous rupture of membranes. Which medication order does the nurse anticipate for this client? Bisacodyl Ampicillin Methergine Dexamethasone
Ampicillin
Seizure activity, sudden cardiac collapse, pulmonary edema, and fetal bradycardia are all signs of which intrapartal complication? Tachysystole Vasa previa Eclampsia Anaphylactic syndrome
Anaphylactic syndrome
Which of the following are expected responses from a patient who has just learned she has premature preterm rupture of membranes (PPROM) and should be admitted for medical management of her pregnancy? Select all that apply. Self-blame and guilt, feeling that she did something to cause this complication Joy and hopefulness at delivering her baby early Anger and frustration Disappointment and fear Ambivalence and apathy
Anger and frustration Disappointment and fear Self-blame and guilt, feeling that she did something to cause this complication
In addition to assessing bowel sounds, what other priority gastrointestinal assessment should be completed on a client following a cesarean section delivery? Assessing for nausea Last bowel movement before surgery Assessing for flatulence Tolerance of a full liquid diet
Assessing for flatulence
Reducing the chances of chorioamnionitis in labor can be done by which of the following? Select all that apply. Avoiding excessive sterile vaginal exams. Avoiding the use of oxytocin in inductions or augmentations. Performing an enema on hospital admit. Only using external monitors for FHM and uterine activity. Performing a cesarean section for primiparous mothers upon SROM.
Avoiding excessive sterile vaginal exams. Only using external monitors for FHM and uterine activity.
The labor nurse is caring for a patient at risk for intraamniotic infection. Which assessment findings would alert the nurse of intraamniotic infection? Select all that apply. Baseline FHR 170 Maternal fever Meconium stained amniotic fluid Severe headache Foul-smelling vaginal discharge
Baseline FHR 170 Maternal fever Foul-smelling vaginal discharge
Bronchopulmonary dysplasia (BPD) is a chronic lung problem associated w/neonates who have been treated with mechanical ventilation. Which assessment is consistent with BPD? Select all that apply. Chest x-ray shows lung hyperinflation ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 Intake matches output for at least 24 hours Lung sounds clear throughout all fields Increased pressure needed for ventilation
Chest x-ray shows lung hyperinflation ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 Increased pressure needed for ventilation
Which complications may occur due to a prolonged rupture of membranes and/or excessive sterile vaginal exams? Select all that apply. Chorioamnionitis Vasa previa Uterine rupture Group beta strep colonization Umbilical cord prolapse
Chorioamnionitis Umbilical cord prolapse
The nurse has been following a gravid patient since her first trimester. The patient has high blood pressure and later develops proteinuria in her third trimester. Which condition is the patient most likely experiencing? Preeclampsia Eclampsia Gestational hypertension Chronic hypertension with superimposed preeclampsia
Chronic hypertension with superimposed preeclampsia
The nurse is caring for a patient that is being induced with oxytocin. Upon assessment of the oxytocin infusion and patient status, the nurse would determine effectiveness with which clinical finding? The patient reports a pain level of 4 on the numeric pain scale with bloody show noted on the peripad. Contractions last 40 to 60 seconds every 2 to 3 minutes with cervical change. Contractions are 4 to 5 minutes apart lasting 30 to 40 seconds with no cervical change. Intensity of contractions is at least 75 to 100 mm/Hg with IUPC.
Contractions last 40 to 60 seconds every 2 to 3 minutes with cervical change.
A mother-baby nurse just received report on four mother baby couplets and is preparing to start the first assessments of the shift. All are recovering from cesarean section deliveries. Which couplet will need to be seen first? Couplet #1: the infant and mother have been doing well since delivery 3 days ago and would like to be discharged in the next couple hours. Couplet #2: the infant has been breastfeeding successfully and the mother has required the uterine fundus to be massaged to firm. Couplet #3: the mother has chosen to bottle feed the infant, and the infant has lost 89 grams of the 3200-gram birth weight at 2 days of age Couplet #4: the infant has been experiencing difficulties latching on to breastfeed and last nursed successfully an hour and a half ago.
Couplet #2: the infant has been breastfeeding successfully and the mother has required the uterine fundus to be massaged to firm.
Which risk factor for hyperbilirubinemia is modifiable? Select all that apply. Mother is Native American Delayed cord clamping Infrequent feedings in first 24 hours Bacterial infection at birth Breast feeding only in first 24 hours
Delayed cord clamping Infrequent feedings in first 24 hours Bacterial infection at birth Breast feeding only in first 24 hours
A laboring patient is experiencing labor dystocia. Which statement correctly describes labor dystocia? Difficult labor characterized by abnormally slow labor progress Fetal shoulder impacted under the maternal symphysis pubis Fetal head larger than maternal pelvis Uterine contractions >25 mm Hg with intrauterine pressure catheter
Difficult labor characterized by abnormally slow labor progress
The nurse is caring for a patient who delivered via cesarean section two hours ago and is now in the recovery room. Upon reviewing the delivery record, the nurse notices that her estimated blood loss was 800mL. What is the appropriate nursing intervention? Document on the report sheet as "normal" and proceed with plan of care. Call the provider to obtain an order for a complete blood count (CBC) and IV fluids. Explain to the patient that she will not be able to breastfeed until her hemoglobin and hematocrit increases by 10%. Prepare the patient for a dilation and curettage (D&C).
Document on the report sheet as "normal" and proceed with plan of care.
The nurse caring for a multiparous patient in active labor suspects cephalopelvic disproportion (CPD). Which assessment finding supports this? Fetal station descending Large maternal stature Tachysystole Fetus not engaged in the pelvis
Fetus not engaged in the pelvis
The labor and delivery unit has had four patients admitted for preterm labor. The nurse recognizes that which patient is not a candidate for tocolysis? G1P0 at 33 weeks' gestation with urinary tract infection G3P1 at 30 weeks' gestation with placental abruption G4P3 at 34 weeks' gestation with positive group B strep G1P0 at 35 weeks' gestation with diabetes and amniocentesis confirming immaturity of fetal lungs
G3P1 at 30 weeks' gestation with placental abruption
The nurse is triaging a postpartum patient who reports heavy vaginal bleeding 7 days after delivering a term infant. The estimated blood loss is 750 mL. Which postpartum complication is she experiencing? Endometritis Uterine atony Early postpartum hemorrhage Late postpartum hemorrhage
Late postpartum hemorrhage
The nurse knows that maternal alcohol, tobacco, cannabis, and cocaine abuse can all cause many long-term adverse effects. Which assessment findings can be attributed to all of these substances? Lower IQ and language problems Congenital infections and congenital anomalies Low birth weight and ADD Mental retardation and aggressiveness
Low birth weight and ADD
A term laboring patient is reporting severe lower back pain and has been pushing for two hours. The nurse would anticipate that the fetus is in which position? Frank breech Occiput posterior Occiput anterior Shoulder presentation
Occiput posterior
The nurse is preparing a client for a cesarean section. Following the epidural anesthesia, the nurse is ready to show the partner where to stay during the surgery. Where does the nurse show the partner to go? On a stool next to the client's head. On a stool next to the infant warmer. In a waiting room next to the operating room. In the recovery room, to await completion of the surgery.
On a stool next to the client's head.
An ectopic pregnancy will often present with which of the following signs and/or symptoms? Painless vaginal bleeding in the second and third trimester Pelvic and abdominal pain with abnormal vaginal bleeding Painless dilatation and expulsion of the fetus Preterm labor between 24 and 37 weeks
Pelvic and abdominal pain with abnormal vaginal bleeding
The nurse is assessing a patient who has been admitted for preeclampsia. Which findings would indicate severe features of preeclampsia? Select all that apply. Blood pressure 158/98 mmHg Platelet count of 90,000/mm3 Severe headache Visual changes Non-pitting edema of lower extremities
Platelet count of 90,000/mm3 Severe headache Visual changes
Following a cesarean section, the nurse caring for the client notes the following assessment data: Temperature 99.1?, Heart rate 136, Respirations 20, Blood pressure 82/48, and skin pale and clammy to the touch. The nurse reports concern of what postpartum complication to the provider? Respiratory depression Renal failure Wound infection Postpartum hemorrhage
Postpartum hemorrhage
The nurse is caring for a gravid patient who is carrying twins. Which complications would the nurse monitor the patient for? Select all that apply. Preeclampsia Gestational diabetes Abruptio placentae Sickle cell anemia Cardiomyopathy
Preeclampsia Gestational diabetes Abruptio placentae Cardiomyopathy
The nurse taking a patient's history at her initial prenatal appointment assesses her risk factors for high-risk pregnancy. Which finding increases her risk for pregnancy complications? Select all that apply. Prior pregnancy complications Current hypertension Father with hypertension Smoking Maternal aunt with breast cancer
Prior pregnancy complications Current htn Smoking
The nurse is caring for a term gestation laboring patient who just had a sudden onset of hypoxia and hypotension shortly after spontaneous rupture of membranes. Which is the nurse's priority action? Assist the patient into High-Fowler's position. Call the provider and prepare for imminent delivery. Draw a blood panel and prepare to administer blood products. Provide supplemental oxygen and left uterine displacement.
Provide supplemental oxygen and left uterine displacement.
A patient who just delivered is experiencing dyspnea, tachycardia, fever, and tachypnea. What postpartum complication is this patient most likely experiencing? Hematoma Mastitis Anaphylactic syndorme Pulmonary embolism
Pulmonary embolism
The nurse is assessing a postpartum patient who had an uncomplicated vaginal delivery one hour ago. Which assessment finding requires immediate intervention? Blood pressure 152/88 mmHg Temperature 99.8 F (37.7 C) Pulse 120 beats/min Respiratory rate 16 breaths/min
Pulse 120 beats/min
The nurse is discharging a woman after hospitalization for preterm labor. The nurse would instruct the patient to call the provider for which signs or symptoms? Select all that apply. Broken bag of water Low back ache with menstrual cramps Heartburn Leg cramps Regular contractions that do not go away with rest
Regular contractions that do not go away with rest Broken bag of water Low back ache with menstrual cramps
The nurse is caring for a patient on the postpartum unit who has been diagnosed with subinvolution post-delivery. The nurse understands that subinvolution is associated with what labor and birth complications? Coagulation disorders such as DIC. Postpartum hemorrhage due to perineal laceration. Uterine tetany and overproduction of oxytocin. Retained placental tissue and infection. Presence of uterine fibroids.
Retained placental tissue and infection. Presence of uterine fibroids.
The nurse is planning care for several postpartum patients. Which nursing actions should be included in the care plan to reduce the risk of postpartum complications? Select all that apply. Review the woman's prenatal and intrapartum records Provide dietary counseling to prevent macrosomia Prevent overdistention of the bladder Encourage bed rest to prevent fatigue. Assess for signs of complications and intervene early
Review the woman's prenatal and intrapartum records Prevent overdistention of the bladder Assess for signs of complications and intervene early
When caring for parents who are grieving after losing an infant, which of the following is the best action? Remind them they can have another child. Ensure that the hospital clergy comes to the room and prays for them. Sit quietly with them and listen. Take the baby to the morgue as soon as possible.
Sit quietly with them and listen.
As you read your patient's fetal heart monitoring strip at the bedside, you notice a category II tracing with contractions every 1 to 1½ minutes for the last 30 minutes. What would be your best response? Make sure the patient is comfortable, perform pericare, and give her positive feedback. Stop the oxytocin drip, turn the patient on her left side, apply a nonrebreather mask flowing at 10 L/min, and administer a 500 mL LR bolus. Encourage the patient to get an epidural to reduce her pain score. Call the provider and recommend an immediate cesarean section to address the chorioamnionitis she's developing.
Stop the oxytocin drip, turn the patient on her left side, apply a nonrebreather mask flowing at 10 L/min, and administer a 500 mL LR bolus.
The nurse is assessing client 12 hours post cesarean section delivery, of a healthy male infant weighing 9 pounds 3 ounces. The client's Foley catheter was removed three hours ago. Which subjective assessment data requires immediate intervention? The client reports pain at a level of four and can tolerate a five. The client reports the infant nursed for about 20 minutes one and a half hours ago. The client has a blood pressure of 92/48. The client reports no voiding since the catheter was removed.
The client reports no voiding since the catheter was removed.
A woman experiencing preterm labor has an order to receive betamethasone. Which statement is correct regarding antenatal corticosteroids? Select all that apply. They reduce the risk of GBS sepsis in the newborn They are most beneficial between 24 and 34 weeks gestation They accelerate fetal lung maturity They reduce the risk of necrotizing enterocolitis in the neonate They decrease the contractility of the uterus
They are most beneficial between 24 and 34 weeks gestation They accelerate fetal lung maturity They reduce the risk of necrotizing enterocolitis in the neonate
Zika is an arbovirus that can infect the neonate in utero. What would the nurse explain as the method of transmission to the parents? Trans-placental transfer Ascending infection Intrapartum exposure Horizontal transmission
Trans-placental transfer
The nurse is assessing a patient and suspects postpartum hemorrhage. Which method of measuring blood loss should the nurse use? Examining all pads and linens for saturation Weigh soaked pads and add the weight of dry pads Use under-buttock calibrated drapes Compare the patient's hemoglobin level to the last hemoglobin level obtained prenatally
Use under-buttock calibrated drapes
A gravid patient is having a trial of labor after cesarean (TOLAC). The nurse knows to watch for which obstetrical emergency? Dystocia Shoulder dystocia Amniotic fluid emboliism Uterine rupture
Uterine rupture
The nurse is caring for patient newly diagnosed with endometritis. What assessment findings are consistent with endometritis? Abdominal cramping and cloudy urine Dizziness and hypotension Edema and hypertension Uterine tenderness and foul-smelling lochia
Uterine tenderness and foul-smelling lochia
One of the best ways to prevent necrotizing enterocolitis is _____________. high flow oxygen therapy nitric oxide therapy delaying cord clamping breastfeeding
breastfeeding
Patient education to prevent infection should focus on _______________. hand hygiene, perineal compression, and douching perineal and hand hygiene, ambulation, hydration perineal and hand hygiene, rest, high-protein diet perineal soaks, hand hygiene, ambulation, analgesia
perineal and hand hygiene, ambulation, hydration
Cesarean sections can often be avoided by providing continuous support by a labor nurse or doula ensuring the woman is moving through the labor phases as quickly as possible encouraging the patient to get an epidural attempting vaginal deliveries more frequently when breech and previa complications arise
providing continuous support by a labor nurse or doula
One of the most commonly occurring complications in infants under 28 weeks gestations is __________________. hyperbilirubinemia sudden infant death syndrome respiratory distress syndrome meconium aspiration syndrome
respiratory distress syndrome
