IYKYK (Maternity)
What is considered to be the "passenger" during childbirth?
Fetus, membranes, placenta
How is the frequency of contractions measured?
From the beginning of one contraction to the beginning of the very next contraction.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately?
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the order.
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?
Observe the mother for other attachment behaviors.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A. Maternal blood pressure B. Maternal temperature C. Fetal heart rate (FHR) D. White blood cell count (WBC)
C. Fetal heart rate (FHR) Be alert for possibility of cord prolapse.
A laboring woman is lying in the supine position. The most appropriate nursing action is to: A. Ask her to turn to one side. B. Elevate her feet and legs. C. Take her blood pressure. D. Determine whether there is fetal tachycardia.
A. The weight of the enlarged uterus may put pressure on the vena cava. reducing blood to her heart.
Nursing interventions for excessive uterine activity during labor. (Also referred to as tachysystole or hypertonic contractions)
* Position onto side. * Administer IV bolus. * If continues, decrease oxytocin. If tachysystole and abnormal fetal heart rate patterns: * Discontinue oxytocin. Administer Terbutaline (Brethine).
3 Types of Breech Presentation
1) Frank Breech 2) Complete Breech 3) Footling Breech
Which of the following are possible causes of fetal tachycardia? Select all that apply. A. dehydration B maternal fever C. hyperthyroidism D. anemia E. hypertension F. opioids G. infection H. cocaine
A B C D G H
A patient comes to the hospital assuming she is in labor. Which assessment finding(s) by the nurse would indicate that the woman is in true labor? (Select all that apply.) A. Pain in the lower back that radiates to abdomen. B. Contractions decreased in frequency with ambulation. C. Progressive cervical dilation and effacement. D. Discomfort localized in the abdomen. E. Regular and rhythmic painful contractions
A,C,E Rationale: These are all signs of true labor (A, C, and E). The others are signs of false labor (B and D).
A client who has experienced a spontaneous abortion at 8 weeks asks the nurse why this happened. What would the nurse include in a response to address the most common cause of "miscarriage"? A. Chromosome Abnormalities B. Environmental Teratogens C. Poor Diet D. Smoking
A. Chromosomal Abnormalities
A client in the prenatal clinic complains of nausea and vomiting. Which intervention should the nurse suggest? A. Eat dry crackers or toast before arising in the morning. B. Consume liquids with meals. C. Eat foods high in fiber. D. Brush teeth right after eating.
A. Eat dry crackers or toast before arising in the morning.Rationale: Eating dry crackers or toast before arising in the morning is a good intervention for aclient complaining of prenatal nausea. Foods high in fiber help with constipation problems, notwith nausea. Brushing teeth after meals can trigger vomiting. Consuming liquids with meals cancause over-distention of the stomach.
A nurse calculates a patient's body mass index (BMI) and finds it to be 37. The nurse understands that this patient is at increased risk for which of the following pregnancy-related outcomes? A. Infertility B. Low Blood Pressure C. Chromosomal Abnormality D. Precipitous Labor
A. Infertility
How many additional calories should a woman consume each day during pregnancy?
An additional 75,000 calories are needed during pregnancy. Daily caloric intake = 2,200 to 2,900 calories.
Which of the following could be a possible cause of vaginal bleeding with or without discomfort) during pregnancy? (Select all that apply.) A. Miscarriage (spontaneous abortion) B. Placenta Previa C. Placental Abruption D. Chorioamnionitis E. Bloody Show F. Sub-Chorionic Hemmorrhage
Answer(s): A, B, C, E, F
Which of the following medications are used to ripen the cervix for an induction of labor: (Select all that apply.) A) Dinoprostone (Cervidil) B) Misoprostol (Cytotec) C) Oxytocin (Pitocin) D) Terbutaline (Brethine)
Answer(s): A, B
A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome? A. Platelet count of 50,000/mcL B. Liver enzyme levels within normal range C. Negative for edema D. No evidence of nausea or vomiting
Answer: A HELLP syndrome is characterized by Hemolysis, Elevated Liver enzyme levels, and a Low platelet count. A platelet count of 50,000/mcL indicates thrombocytopenia.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following? A. Hemorrhage is the primary concern. B. She will be unable to conceive in the future. C. Bed rest and analgesics are the recommended treatment. D. A D&C will be performed to remove the products of conception.
Answer: A Severe bleeding occurs if the fallopian tube ruptures. If the tube must be removed, the patient's fertility will decrease; however, she will be able to achieve a future pregnancy. The recommended treatment is to remove the pregnancy before hemorrhage occurs. A D&C is done on the inside of the uterine cavity. The ectopic is located within the tubes.
Which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa? A. Determining cervical dilation and effacement. B. Monitoring FHR and maternal vital signs. C. Observing vaginal bleeding or leakage of amniotic fluid. D. Determining frequency, duration, and intensity of contractions
Answer: A Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage. Monitoring FHR and maternal vital signs is a necessary part of the assessment for this patient. Monitoring for bleeding and rupture of membranes is not contraindicated with this patient. Monitoring contractions is not contraindicated with this patient.
Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? S. Hypoglycemia B. Hypercalcemia C. Hypoinsulinemia D. Hypobilirubinemia
Answer: A he neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops, and the neonatal insulin exceeds the available glucose, leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Because fetal insulin production is accelerated during pregnancy, the neonate shows hyperinsulinemia. Excess erythrocytes are broken down after birth, releasing large amounts of bilirubin into the neonate's circulation,which results in hyperbilirubinemia.
A patient tells you her last menstrual period was September 10th, 2014. According to the Naegele's rule when is her expected due date? A. June 17, 2015 B. May 17, 2015 C. June 10, 2015 D. June 10, 2014
Answer: A. Determine the first day of the last menstrual period. Count back 3 calendar months from that date. Add 1 year and 7 days to that date.
Which assessment by the nurse would differentiate a placenta previa from a placental abruption? A. Saturated perineal pad in 1 hour B. Pain level 0 on a scale of 0 to 10 C. Cervical dilation at 2 cm D. Fetal heart rate at 160 bpm
Answer: B The classic sign of placenta previa is the sudden onset of painless uterine bleeding, whereas abruptio placentae results in abdominal pain and uterine tenderness; heavy bleeding, cervical dilation, and fetal heart rate of 160 bpm could be associated with both conditions.
Which maternal condition always necessitates delivery by cesarean birth? A. Partial abruptio placentae B. Total placenta previa C. Ectopic pregnancy D. Eclampsia
Answer: B In total placenta previa, the placenta completely covers the cervical os. The fetus would die if vaginal birth occurred. If the patient has stable vital signs and the fetus is alive, a vaginal birth can be attempted. If the fetus has already expired, a vaginal birth is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A. Cyanosis of the hands and feet B. Skin color that is slightly jaundiced C. Tiny white papules on the nose or chin D. Red patches on the cheeks and trunk
Answer: C. (C) reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although (A) is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. (B) is condescending and dismissing; the mother is seeking reassurance and information. (D) is a negative statement and implies that molding is the mother's fault.
A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? A. "This is not an unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." C. "That is normal. The head will return to a round shape within 7 to 10 days." D. "Your pelvis was too small, so the head had to adjust to the birth canal."
Answer: C. "That is normal. The head will return to a round shape within 7 to 10 days."
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again.
Answer: C. The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself (C). After such a time out, breastfeeding is often more successful. (A and D) would cause nipple confusion. (B) would only cause the infant to be more resistant, resulting in the mother and infant to become more frustrated.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband attend childbirth preparation classes. When is the best time for the couple to participate in these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation
At 30-weeks gestation is closest to the time parents would be ready for such classes. Learning is facilitated by an interested pupil! The couple is most interested in childbirth toward the end of the pregnancy when they are psychologically ready for the termination of the pregnancy, and the birth of their child is an immediate concern.
A nurse is teaching a group of prenatal clients about the importance of exercise during pregnancy. Which client would be the best candidate to continue with her exercise regime? A. A client with placenta previa. B. A client with a diagnosis of diabetes. C. A client with a diagnosis of pre-eclampsia. D. A client with an incompetent cervix and cerclage
B. A client with a diagnosis of diabetes.Rationale: Exercise would be therapeutic in helping a client with a diagnosis of diabetes to control her glucose utilization. However, it would be contraindicated in a client with an incompetent cervix and cerclage, a client with a diagnosis of preeclampsia, or a client with placenta previa.
A nurse is explaining to a young woman who is trying to become pregnant about the process of conception. Which organ should the nurse mention as the site at which fertilization takes place? A. Ovaries B. Fallopian Tube C. Uterus D. Cervix
B. Fallopian Tube
Which of the following is NOT an example of an autosomal-recessive disorders? A. Sickle Cell Anemia B. Huntington's Disease C. PKU D. Cystic Fibrosis
B. Huntingtons's Disease
During a vaginal assessment on a patient who is 8 weeks pregnant, you note a bluish coloration of the mucous membrane of the cervix, vagina, and vulva. You would document this finding as what?* A. Hegar's Sign B. Ballottement C. Chadwick's Sign D. Goodell's Sign
C. Chadwick's Sign
A nurse observes a patient, who has recently given birth, interacting with her mother, who is visiting her and the baby. The patient and her mother both share the same eye and hair color and are about the same height. The nurse knows that these traits are examples of which of the following? A. Genotypes B. Genomes C. Phenotypes D. Karyotypes
C. Phenotypes
A pregnant patient tells the prenatal nurse she has been having some "unusual food cravings." After further assessment, the nurse discovers the patient has been ingesting white clay dirt from her backyard. Which laboratory study indicates a physiological consequence of the patient's action? A. WBC 12,300 B. Glucose 96 C. Hemoglobin 9.1 D. Platelets of 250,000
C. Pica is usually a result of mineral deficiency, many times iron.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A. Drowsiness and paroxysmal bradycardia B. Depressed reflexes and increased respirations C. Tachycardia and a feeling of nervousness D. A flushed warm feeling and dry mouth
C. Tachycardia and a feeling of nervousness
Why is childbirth pain unique?
Childbirth pain is unique because it is both normal and self-limiting.
The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: A. "Nausea and vomiting can be decreased if I eat a few crackers before rising." B. "If I start to leak colostrum, I should cleanse my nipples with soap and water." C. "If I have a vaginal discharge, I should wear nylon underwear." D. "Leg cramps can be alleviated if I put an ice pack on the area."
Correct Answer: A. "Nausea and vomiting can be decreased if I eat a few crackers before arising" Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help. Option B: Colostrum is a milky fluid that's released by mammals that have recently given birth before breast milk production begins. Option C: Cotton underwear is breathable and absorbent, which can help prevent yeast infections. Option D: A heating pad or hot pack may help relieve tight muscles in leg cramps.
Which of the following is the most common kind of placental adherence seen in pregnant women? A. Accreta B. Placenta previa C. Percreta D. Increta
Correct Answer: A. Accreta Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium. Option B: In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the patient's risk for painless vaginal bleeding during the pregnancy and/or delivery process. Option C: Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete. Option D: Placenta increta leads to deep penetration of the myometrium.
A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? A. Activity limited to bed rest. B. Platelet infusion. C. Immediate cesarean delivery. D. Labor induction with oxytocin.
Correct Answer: A. Activity limited to bed rest Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding. Option B: The greatest risk of placenta previa is hemorrhage. Bleeding often occurs as the lower part of the uterus thins during the third trimester of pregnancy in preparation for labor. This may require blood transfusion during Cesarean section. Option C: In general, there is a higher Cesarean rate associated with placental edge-to-cervical os distances of less than 2 cm. Option D: Labor induction is the stimulation of uterine contractions during pregnancy before labor begins on its own to achieve a vaginal birth. It is not an option for placenta previa.
A patient is in her last trimester of pregnancy. Nurse Vickie should instruct her to notify her primary health care provider immediately if she notices: A. Blurred vision B. Hemorrhoids C. Increased vaginal mucus D. Shortness of breath on exertion
Correct Answer: A. Blurred vision Blurred vision or other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus. Option B: Although hemorrhoids may be a problem during pregnancy, they do not require immediate attention. Hemorrhoids occur when the external hemorrhoidal veins become varicose (enlarged and swollen), which causes itching, burning, painful swellings at the anus, dyschezia (painful bowel movements), and bleeding. Option C: Almost all women have more vaginal discharge in pregnancy. This is normal, and helps prevent any infections travelling up from the vagina to the womb. Towards the end of pregnancy, the amount of discharge increases further. In the last week or so of pregnancy, it may contain streaks of sticky, jelly-like pink mucus. Option D: Dyspnea can begin before any upward displacement of the diaphragm, suggesting that factors other than mechanical pressure may be involved. It probably results from the subjective awareness of hyperventilation that is universally present in pregnancy. Hyperventilation in pregnancy is predominantly due to an increase in the depth of the tidal volume, with little change in the respiratory rate
Normal lochial findings in the first 24 hours post-delivery include: A. Bright red blood B. Large clots or tissue fragments C. A foul odor D. The complete absence of lochia
Correct Answer: A. Bright red blood Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia. Option B: The blood clots in the lochia should get smaller and happen less often as the bleeding gets less over the first few days. Option C: Lochia with offensive odor may indicate infection. Option D: Complete absence of lochia might be a sign of infection.
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? A. Change the client's position. B. Prepare for an emergency cesarean section. C. Check for placenta previa. D. Administer oxygen.
Correct Answer: A. Change the client's position. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position from supine to side-lying may immediately correct the problem. Option B: An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Option C: Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent. It does not include placenta previa. Option D: Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression. The fetus already has a surplus of oxygen due to high basal blood flow to its organs and vascular shunts.
Immediately after delivery, the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding? A. Fetal body flexion or extension B. Maternal age, body frame, and weight C. Maternal and paternal ethnic backgrounds D. Maternal parity and gravidity
Correct Answer: A. Fetal body flexion or extension Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head of a neonate. Option B: When a baby is born in a cephalic position, pressure on the head in the birth canal may mold the head into an oblong shape. The mother's age, body frame, and weight do not affect the pressure. Option C: There is research that indicates that infant head molding, the application of pressure or bindings to cranial bones to alter their shapes, is prevalent among various Caribbean, Latino, European, African American, Asian, and Native American groups. Option D: Infants born by primiparous women showed significantly higher degrees of molding of the head than those born by multiparous women.
The multigravida mother with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" Which of the following would be the nurse's first action? A. Inspect the perineum. B. Time the contractions. C. Auscultate the fetal heart rate. D. Contact the birth attendant.
Correct Answer: A. Inspect the perineum When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client's statement. If the client is not delivering precipitously, the nurse can calm her and use appropriate breathing techniques. Option B: The woman has a history of rapid labor and is already experiencing true labor contractions. There is no need to time the contractions experienced. Option C: Fetal heart rate monitoring is being consistently monitored during labor. The client's concerns about the delivery of the baby must be prioritized. Option D: Before contacting a birth attendant or the physician, validate the client's claims first. If she is not yet delivering, instruct about breathing techniques that may ease her discomfort.
Because cervical effacement and dilation are not progressing in a patient in labor, the doctor orders I.V. administration of oxytocin (Pitocin). Why should the nurse monitor the patient's fluid intake and output closely during oxytocin administration? A. Oxytocin causes water intoxication. B. Oxytocin causes excessive thirst. C. Oxytocin is toxic to the kidneys. D. Oxytocin has a diuretic effect.
Correct Answer: A. Oxytocin causes water intoxication. The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. In addition, oxytocin may cause water intoxication via an antidiuretic hormone-like activity when administered in excessive doses with electrolyte-free solution. Option B: Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin. Option C: Oxytocin, when given in rapid bolus, produces marked but short-lived hypotension and tachycardia. Sometimes, this abrupt and severe hemodynamic depression may need to be distinguished from placental abruption, myocardial infarction, or a pulmonary embolism in patients undergoing delivery. Option D: Oxytocin is known to possess antidiuretic properties. It can function physiologically as an antidiuretic hormone, mimicking the short-term action of vasopressin on water permeability, albeit with somewhat lower potency.
When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to: A. Prevent seizures. B. Reduce blood pressure. C. Slow the process of labor. D. Increase diuresis.
Correct Answer: A. Prevent seizures The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyper-stimulated neurologic system by interfering with signal transmission at the neuromuscular junction. Option B: Magnesium sulfate may attenuate blood pressure by decreasing the vascular response to pressor substances. Option C: Since the primary therapeutic goal of tocolysis is to delay preterm delivery within 48 hours from the initiation of steroid prophylaxis, little evidence suggests that extended MgSO4 therapy is beneficial. Option D: There are rare cases of pregnant women who develop polyuria after receiving intravenous therapy of magnesium sulfate. It can be considered as another cause of solute diuresis
The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? A. Risk for deficient fluid volume related to hemorrhage. B. Risk for infection related to the type of delivery. C. Pain related to the type of incision. D. Urinary retention related to periurethral edema.
Correct Answer: A. Risk for deficient fluid volume related to hemorrhage Hemorrhage jeopardizes the client's oxygen supply — the first priority among human physiological needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over-diagnoses of Risk for Infection, Pain, and Urinary retention. Option B: Episiotomy infections are classically reported as being rare at a rate of 0.1% and increasing up to 2% if a third or fourth-degree tear occurs. Option C: Episiotomy pain may be relieved by an ice pack, warm or cold shallow baths or sitz baths, or medicated creams or local numbing sprays. Option D: Postpartum urinary retention (PPUR) is an upsetting condition that has no standard literature definition. It has been variably defined as the abrupt onset of aching or inability to completely micturate, requiring urinary catheterization, over 12 hours after giving birth or not to void spontaneously within 6 hours of vaginal delivery.
After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective? A. Shortens the second stage of labor. B. Enlarges the pelvic inlet. C. Prevents perineal edema. D. Ensures quick placenta delivery.
Correct Answer: A. Shortens the second stage of labor An episiotomy serves several purposes. It shortens the second stage of labor, substitutes a clean surgical incision for a tear, and decreases undue stretching of perineal muscles. An episiotomy helps prevent tearing of the rectum but it does not necessarily relieve pressure on the rectum. Tearing may still occur. Option B: The pelvic inlet or superior aperture of the pelvis is a planar surface that defines the boundary between the pelvic cavity and the abdominal cavity. It is not involved during an episiotomy. Option C: To prevent perineal edema, ice packs may be applied in the first 24 hours after birth to decrease swelling and pain. Option D: Placenta delivery may be sped up by either pulling the cord gently with one hand while pressing and kneading the uterus with the other, or exerting downward pressure on the top of the uterus, asking the woman to push at the appropriate time.
When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands open, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? A. Startle reflex B. Babinski reflex C. Grasping reflex D. Tonic neck reflex
Correct Answer: A. Startle reflex The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months. Option B: Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toe fan out. Option C: Palmar grasp reflex appears around 16 weeks of gestation and can be elicited in preterm infants as young as 25 weeks of postconceptional age. To elicit the reflex, the infant is laid in a symmetrical supine and the examiner strokes the palm of the infant with his or her index finger. The response to this stimulus comprises two phases: finger closing and clinging. Option D: When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. The tonic neck reflex lasts until the infant is about 5 to 7 months old.
Which behaviors would be exhibited during the letting-go phase of maternal role adaptation. Select all that apply. A. Emergence of the family unit. B. Dependent behaviors. C. Sexual intimacy continues. D. Defining one's individual roles. E. Being talkative and excited about becoming a mother.
Correct Answer: Answer: A, C, & D The emergence of family unit, sexual intimacy relationship continuing and defining one's individual roles represent interdependent behaviors associated with the letting-go phase. During the letting go phase, the woman finally accepts her new role and gives up her old roles like being a childless woman or just a mother of one child. Option B: Dependent behaviors are exhibited in the taking-in phase. The taking-in phase is the time of reflection for the woman because within the 2 to 3 day period, the woman is passive. Option E: Being talkative and excited about becoming a mother represents the taking-hold phase and is an example of dependent-independent behaviors. The woman starts to initiate actions on her own and makes decisions without relying on others.
A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse's plan of care after the procedure? Select all that apply. A. Perform ultrasound to determine fetal positioning. B. Observe the patient for possible uterine contractions. C. Administer RhoGAM to the patient if she is Rh-negative. D. Perform a mini catheterization to obtain a urine specimen to assess for bleeding.
Correct Answer: B & C Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of the transabdominal needle. RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood. RhoGAM is administered by intramuscular (IM) injection. RhoGAM is purified from human plasma containing anti-Rh (anti-D). Option A: The position of the baby in the uterus is called the presentation of the fetus. Ideally for labor, the baby is positioned head-down, facing the mother's back with the chin tucked to its chest and the back of the head ready to enter the pelvis. This position is called cephalic presentation. Option D: There is no need to assess the urine for bleeding as this is not considered to be a typical presentation or complication.
When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her? A. "I'll report increased frequency of urination." B. "If I have blurred or double vision, I should call the clinic immediately." C. "If I feel tired after resting, I should report it immediately." D. "Nausea should be reported immediately."
Correct Answer: B. "If I have blurred or double vision, I should call the clinic immediately." Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. It can affect the visual pathways, from the anterior segment to the visual cortex. Option A: Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. The anatomical and physiological changes affecting the lower urinary tract in pregnancy, as well as the hormonal milieu of pregnancy, have been postulated to underlie the pathogenesis of lower urinary symptoms in pregnancy Option C: Clients generally experience fatigue during pregnancy. Pregnancy is accompanied by several psychological, emotional, and physical changes that may predispose the woman to fatigue, which can range from mild tiredness to severe exhaustion. Option D: The pathophysiology of nausea and vomiting during early pregnancy is unknown, although metabolic, endocrine, GI, and psychologic factors probably all play a role. Estrogen may contribute because estrogen levels are elevated in patients with hyperemesis gravidarum.
A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond? A. "Yes, it produces no adverse effect." B. "No, it can initiate premature uterine contractions." C. "No, it can promote sodium retention." D. "No, it can lead to increased absorption of fat-soluble vitamins."
Correct Answer: B. "No, it can initiate premature uterine contractions." Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Option A: Castor oil is a harsh stimulant laxative that relieves constipation by forced bowel movements. Side effects may include nausea, stimulation of uterine activity, meconium-stained fluid, and amniotic fluid embolism. Option C: There is no evidence that suggests that castor oil can promote sodium retention. Option D: Castor oil is not known to increase absorption of fat-soluble vitamins, although laxatives, in general, may decrease absorption if intestinal motility is increased.
What is the approximate time that the blastocyst spends traveling to the uterus for implantation? A. 2 days B. 7 days C. 10 days D. 14 weeks
Correct Answer: B. 7 days The blastocyst takes approximately 1 week to travel to the uterus for implantation. Implantation is a process in which a developing embryo, moving as a blastocyst through a uterus, makes contact with the uterine wall and remains attached to it until birth. Option A: The zygote moves through the fallopian tube and undergoes cell division, a process called cleavage. These cell divisions produce the inner cell mass (ICM), which will become the embryo, and the trophoblast, which surrounds the ICM and interacts with maternal tissues. Together, the ICM and the trophoblast are called the blastocyst. Option C: A blastocyst successfully implants in the uterus when, as the zona pellucida exits the fallopian tube, the blastocyst leaves the zona pellucida and binds to the endometrium. Option D: 14 weeks is too long a time to wait for implantation. If the blastocyst does not implant within 7 days, the pregnancy may not occur at all.
A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client's complaint of vaginal bleeding? A. Placenta previa B. Abruptio placentae C. Ectopic pregnancy D. Spontaneous abortion
Correct Answer: B. Abruptio placentae The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruptio placentae. The hypertension and increased levels of catecholamines caused by cocaine abuse are thought to be responsible for a vasospasm in the uterine blood vessels that causes placental separation and abruption. Option A: A pregnant woman who uses cocaine experiences a constriction of the blood vessels throughout her body. A fetus needs this blood flow for its oxygen supply. After cocaine abuse, the heart rate of the fetus goes up along with the blood pressure, but it may suffer a lack of oxygen (hypoxia). This restricted blood supply can also permanently damage sections of the placenta which can result in loss of the baby. Option C: Ectopic pregnancy (EP) is defined as the implantation and development of a fertilized ovum anywhere outside of the uterine cavity. Such a pregnancy may lead to tubal rupture and intra abdominal hemorrhage and represents the major cause of maternal death in the first trimester. Option D: Cocaine use early in pregnancy decreases uterine and placental blood flow by inhibiting the reuptake of norepinephrine, which causes arterial vasoconstriction. In most, but not all, previous studies of cocaine use during pregnancy and spontaneous abortion, the women's current use of cocaine, as assessed by self-reports or urine analysis, was related to their history of spontaneous abortion.
The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation. C. Between 21 and 23 weeks' gestation. D. Between 24 and 26 weeks' gestation.
Correct Answer: B. Between 16 and 20 weeks' gestation. A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks' gestation. Option A: Before 16 weeks, the fetus is not developed enough for the woman to detect movement. Option C: After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins. Option D: After 24 weeks, the fetus might be able to respond to familiar sounds such as its mother's voice, with movement. It is spending most of its sleep time in rapid eye movement (REM).
A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this patient? A. Knowledge deficit B. Fluid volume deficit C. Anticipatory grieving D. Pain
Correct Answer: B. Fluid volume deficit If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be instituted. Blood volume expands during pregnancy, and a considerable portion of the weight of a pregnant woman is retained water. Option A: Knowledge deficit is an appropriate nursing diagnosis because the woman might not have any knowledge on how to manage her symptoms. However, this is not a priority diagnosis. Option C: Anticipatory grieving is the name given to the tumultuous set of feelings and reactions that occur when someone is expecting the death of a loved one. Option D: Pain may be felt due to abdominal cramping accompanied by bleeding. This is not a cause of alarm since true labor pain includes strong and regular contractions and lower back pain.
With regard to small-for-gestational-age (SGA) infants and intrauterine growth restriction (IUGR), nurses should be aware that: A. In the first trimester, diseases or abnormalities result in asymmetric IUGR. B. Infants with asymmetric IUGR have the potential for normal growth and development. C. In asymmetric IUGR, weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA. D. Symmetric IUGR occurs in the later stages of pregnancy.
Correct Answer: B. Infants with asymmetric IUGR have the potential for normal growth and development. The infant with asymmetric IUGR has the potential for normal growth and development. SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Option A: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities. Option C: Weight is less than the 10th percentile, but the head circumference is greater than the 10th percentile (within normal limits). Option D: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities.
Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? A. Applying cold to limit edema during the first 12 to 24 hours. B. Instructing the client to use two or more peri pads to cushion the area. C. Instructing the client on the use of sitz baths if ordered. D. Instructing the client about the importance of perineal (Kegel) exercises.
Correct Answer: B. Instructing the client to use two or more peri pads to cushion the area Using two or more peripads would do little to reduce the pain or promote perineal healing. A fourth-degree perineal laceration is the injury to the perineum involving the anal sphincter complex and anorectal mucosa. Option A: Ice packs can help reduce pain and swelling in the perineum. Use ice cubes in a clean, disposable glove. Wrapped in a damp cloth or place the ice pack inside a pad. Never apply directly on skin. Apply for 10-20 minutes. Repeat every 2-3 hours until pain and swelling decrease. Option C: Hot sitz bath may help speed up the healing process. Use sitz baths a few times a day, 24 hours after giving birth. Sit in water that covers the vulvar area. Option D: The muscles lie deep in the pelvis and support the pelvic organs and control the bladder and bowel function. The pelvic floor muscles attach to the pubic bone at the front, tail bone at the back, and from one sitting bone to the other sitting bone. It is important to retrain the muscles after a tear, to prevent problems such as incontinence.
What is an appropriate indicator for performing a contraction stress test? A. Increased fetal movement and small for gestational age. B. Maternal diabetes mellitus and postmaturity. C. Adolescent pregnancy and poor prenatal care. D. History of preterm labor and intrauterine growth restriction.
Correct Answer: B. Maternal diabetes mellitus and postmaturity. The contraction stress test helps predict how the baby will do during labor. The test triggers contractions and registers how the baby's heart reacts. A normal heartbeat is a good sign that the baby will be healthy during labor. Option A: Decreased fetal movement is an indicator for performing a contraction stress test; the size (small for gestational age) is not an indicator. Option C: Although adolescent pregnancy and poor prenatal care are risk factors for poor fetal outcomes, they are not indicators for performing a contraction stress test. Option D: Intrauterine growth restriction is an indicator; history of a previous stillbirth, not preterm labor, is another indicator.
When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse in charge should include which of the following? A. The vaccine prevents a future fetus from developing congenital anomalies. B. Pregnancy should be avoided for 3 months after the immunization. C. The client should avoid contact with children diagnosed with rubella. D. The injection will provide immunity against the 7-day measles.
Correct Answer: B. Pregnancy should be avoided for 3 months after the immunization After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccine's toxic effects to the fetus. Option A: The role of the vaccine postpartum is to protect the mother against rubella in the future pregnancies as well as measles and mumps, since it is given together. Option C: Protection against measles, mumps, and rubella starts to develop around 2 weeks after having the MMR vaccine. Option D: One dose of MMR vaccine is 93% effective against measles, 78% effective against mumps, and 97% effective against rubella.
A client who's admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? A. Placing the client in bed to begin fetal monitoring. B. Preparing for immediate delivery. C. Checking for ruptured membranes. D. Providing comfort measures.
Correct Answer: B. Preparing for immediate delivery. This question requires an understanding of station as part of the intrapartum assessment process. Based on the client's assessment findings, this client is ready for delivery, which is the nurse's top priority. Option A: Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed. Option C: The membranes can break by themselves. This is called a spontaneous rupture of the membranes. It most often happens after active labor has started. Option D: Comfort measures may be given to the woman after ensuring all necessary measures to help her deliver successfully.
While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy? A. Calcium gluconate B. Protamine sulfate C. Methylergonovine (Methergine) D. Nitrofurantoin (Macrodantin)
Correct Answer: B. Protamine sulfate Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose. Option A: Calcium gluconate is the calcium salt of gluconic acid, an intravenous medication used to treat conditions arising from calcium deficiencies such as hypocalcemic tetany and hypocalcemia. Option C: Methylergonovine is used to prevent or treat bleeding from the uterus that can happen after childbirth or an abortion. Option D: Nitrofurantoin is used to treat urinary tract infections. It is an antibiotic that works by killing bacteria that cause infection.
Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? A. Excessive vaginal bleeding B. Rigid, board-like abdomen C. Tetanic uterine contractions D. Premature rupture of membranes
Correct Answer: B. Rigid, board-like abdomen The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. Option A: It's possible for the blood to become trapped inside the uterus, so even with a severe placental abruption, there might be no visible bleeding. Option C: Uterine contractions are a common finding with placental abruption. Contractions progress as the abruption expands, and uterine hypertonus may be noted. Contractions are painful and palpable. Option D: Increased frequency of placental abruption was found in patients with early rupture of membranes. The incidence was 50% and 44% when rupture of the membranes occurred before 20 weeks or between 20-24 weeks of pregnancy, respectively.
The nurse in-charge is reviewing a patient's prenatal history. Which finding indicates a genetic risk factor? A. The patient is 25 years old. B. The patient has a child with cystic fibrosis. C. The patient was exposed to rubella at 36 weeks' gestation. D. The patient has a history of preterm labor at 32 weeks' gestation.
Correct Answer: B. The patient has a child with cystic fibrosis Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Option A: Maternal age is not a risk factor until age 35, when the incidence of chromosomal defects increases. Option C: Maternal exposure to rubella during the first trimester may cause congenital defects. Option D: Although a history or preterm labor may place the patient at risk for preterm labor, it does not correlate with genetic defects.
A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta. B. The ultrasound identifies blood flow through the umbilical cord. C. The test will determine where to insert the needle. D. The ultrasound locates a pool of amniotic fluid.
Correct Answer: B. The ultrasound identifies blood flow through the umbilical cord. Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this. Option A: As early as 10 weeks, the placenta can be detected by an ultrasound. The normal placenta is discoid with uniform echogenicity and rounded margins. It is usually located along the anterior or posterior uterine walls, extending into the lateral walls. Option C: Ultrasound is done before and during amniocentesis to ensure that the needle can safely pass through the walls of the abdomen and womb. Option D: The sample of amniotic fluid is removed through a fine needle inserted into the uterus through the abdomen, under ultrasound guidance.
Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first? A. "Do you have any chronic illness?" B. "Do you have any allergies?" C. "What is your expected due date?" D. "Who will be with you during labor?"
Correct Answer: C. "What is your expected due date?" When obtaining the history of a patient who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons. Option A: After asking for the expected due date, obtain the client's problems during this or previous pregnancies. Option B: Asking about any known allergies may be done after inquiring about prior ultrasonographic examinations and results, and bleeding during pregnancy or labor. Option D: This may be asked if the client's health history and present health history, which are some of the most important details, are already obtained.
After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at (-1) station. Based on these findings, the nurse-midwife knows that the fetal presenting part is: A. 1 cm below the ischial spines. B. Directly in line with the ischial spines. C. 1 cm above the ischial spines. D. In no relationship to the ischial spines.
Correct Answer: C. 1 cm above the ischial spines. Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as -1, -2, or -3. Option A: A presenting part below the ischial spines, as +1, +2, or +3. Option B: 0 station is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis. Option D: If the head is high and not yet engaged in the birth canal, it may float away from the physician's fingers during the vaginal exam.
The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A. Feeding the neonate a maximum of 5 minutes per side on the first day. B. Wearing a supportive brassiere with nipple shields. C. Breastfeeding the neonate at frequent intervals. D. Decreasing fluid intake for the first 24 to 48 hours.
Correct Answer: C. Breastfeeding the neonate at frequent intervals Prevention of breast engorgement is key. The best technique is to empty the breast regularly while feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate's and mother's needs. Option A: A newborn feeds every 2 to 3 hours. They should be breastfed 8-12 times per day for about the first month. Frequent feedings help stimulate your milk production during the first few weeks. Option B: A nipple shield is usually meant to be used for a short time. When using a shield, help the baby to latch on by himself with a wide-open mouth. This will help the baby learn to breastfeed without a shield. Option D: Breastfeeding women are recommended to increase fluid intake by 800 ml/day during the first 6 months postpartum.
Why is the incidence of ectopic pregnancy increasing in the United States?
The rate of sexually transmitted diseases is increasing. STD's can cause pelvic inflammation.
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide a formula for the infant until he becomes calm, and then offer the breast again.
Correct Answer: C. Encourage the mother to stop feeding for a few minutes and comfort the infant. The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful. Option A: Concern about pacifiers for breastfeeding infants focuses on "nipple confusion"—that is, that pacifiers (and supplemental bottles) do not facilitate effective breast sucking and may contribute to incorrect latch. Findings from earlier observational studies suggest that early exposure to pacifiers leads to cessation of exclusive breastfeeding by 3 to 6 months and an end to all breastfeeding by 12 months. Option B: Option B would only cause the infant to be more resistant, resulting in the mother and infant to become more frustrated. Option D: When using an average baby bottle, babies don't have to work as hard because gravity and the nipple cause the milk flow to be more continuous for the baby. Nipple confusion occurs when the baby switches back to breast, and doesn't understand why the milk flows differently than it did with the bottle.
In the past, factors to determine whether a woman was likely to have a high-risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high-risk pregnancy has been adopted. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. Which of the options listed here is not included as a category? A. Biophysical B. Psychosocial C. Geographic D. Environmental
Correct Answer: C. Geographic The fourth category is correctly referred to as the sociodemographic risk category. Several risk factors for high-risk pregnancy were present before pregnancy, including multiple pregnancies, maternal age under 16 or over 35 years, and interval between pregnancies less than one year. Option A: A fetal biophysical profile is a prenatal test used to check on a baby's well-being. The test combines fetal heart rate monitoring (nonstress test) and fetal ultrasound to evaluate a baby's heart rate, breathing, movements, muscle tone and amniotic fluid level. Option B: A pregnancy may be determined to be at high risk because of obstetric factors in previous pregnancies or the present one; conditions that are, themselves, psychosocial: anxiety disorders (GAD, OCD, panic disorder, PTSD), mood disorders, and schizophrenia, all of which are a background for a disturbed pregnancy and might complicate a pregnancy denominated high risk for some other reason. Option D: Environmental factors that have been implicated in adverse pregnancy outcomes include smoking, video display terminals, anesthetic gases, antineoplastic drugs and exposure to lead, selenium and inorganic mercury.
The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis
Correct Answer: C. Gonorrhea Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Option A: Antibiotics do not work for viruses like herpes. Taking antibiotics when they are not really needed increases the risk of getting infection later that resists antibiotic treatment. Option B: Trichomoniasis can be cured with a single dose of prescription antibiotic medication (either metronidazole or tinidazole), pills that can be taken by mouth. Option D: A single intramuscular injection of long-acting Benzathine penicillin G (2.4 million units administered intramuscularly) will cure a person who has primary, secondary, or early latent syphilis. Three doses of long-acting Benzathine penicillin G (2.4 million units administered intramuscularly) at weekly intervals is recommended for individuals with late latent syphilis or latent syphilis of unknown duration. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation. B. Alteration in comfort related to nausea and abdominal distention. C. Impaired bowel motility related to pain medication and immobility. D. Fatigue related to cesarean delivery and physical care demands of infant.
Correct Answer: C. Impaired bowel motility related to pain medication and immobility Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Option A: Altered nutrition is also an appropriate diagnosis since the woman was not able to eat adequately since the surgery, hindering her ability to breastfeed. However, it can be managed and is not the priority at the time. Option B: The woman's comfort is also altered due to nausea and bloating, but it is not considered a priority. Option D: After cesarean delivery, fatigue may overcome the client's desire to eat and breastfeed her infant. This is a correct diagnosis but it does not take priority over impaired bowel motility.
A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A. Sometimes uses vibroacoustic stimulation. B. Is an invasive test; however, contractions are stimulated. C. Is considered to have a negative result if no late decelerations are observed with the contractions. D. Is more effective than nonstress test (NST) if the membranes have already been ruptured.
Correct Answer: C. Is considered to have a negative result if no late decelerations are observed with the contractions. No late decelerations indicate a positive CST result. Option A: Vibroacoustic stimulation is sometimes used with NST. Vibroacoustic stimulation (VAS) of the fetus has been used as both a primary and adjunctive method of FHR testing. This device produces a broadband acoustic signal and a complex vibratory component. Option B: CST is invasive if stimulation is performed by IV oxytocin but not if by nipple stimulation. Option D: CST is contraindicated if the membranes have ruptured.
The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A. Active phase B. Complete phase C. Latent phase D. Transitional phase
Correct Answer: D. Transitional phase The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. Option A: The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. Option B: The complete phase occurs during the second, not first, stage of labor. Option C: The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.
A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? A. Proteinuria, headaches, vaginal bleeding B. Headaches, double vision, vaginal bleeding C. Proteinuria, headaches, double vision D. Proteinuria, double vision, uterine contractions
Correct Answer: C. Proteinuria, headaches, double vision A patient with pregnancy-induced hypertension complains of a headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Option A: Pre-eclampsia increases the risk for placental abruption, a condition in which the placenta separates from the inner wall of the uterus before delivery. Severe abruption can cause heavy bleeding, which can be life-threatening for both the baby and the mother. Option B: Any hypertensive disorder of pregnancy can result in preeclampsia. It occurs in up to 35% of women with gestational hypertension and up to 25% of those with chronic hypertension. The underlying pathophysiology that upholds this transition to, or superposition of, preeclampsia is not well understood; however, it is thought to be related to a mechanism of reduced placental perfusion inducing the systemic vascular endothelial dysfunction. Option D: Symptoms of preeclampsia may include visual disturbances, typically scintillations and scotomata, presumed to be due to cerebral vasospasm. The woman may describe new-onset headache that is frontal, throbbing, or similar to a migraine headache, and gastrointestinal complaints of sudden, new-onset, constant epigastric pain that may be moderate to severe in intensity and due to hepatic swelling and inflammation, with stretch of the liver capsule.
Forty-eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following? A. Taking in B. Letting go C. Taking hold D. Resolution
Correct Answer: C. Taking hold Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills. Option A: The taking-in phase usually sets 1 to 2 days after delivery. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role. Option B: During the letting go phase, the woman finally accepts her new role and gives up her old roles like being a childless woman or just mother of one child. Option D: The resolution phase or ending phase is the final stage of the nurse-client relationship. After the client's problems or issues are addressed, the relationship needs to be completed before it can be terminated.
A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? A. The fetus should be delivered within 24 hours. B. The client should repeat the test in 24 hours. C. The fetus isn't in distress at this time. D. The client should repeat the test in 1 week.
Correct Answer: C. The fetus isn't in distress at this time. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits. Option A: The biophysical profile is a test used to evaluate the well-being of the fetus. It is commonly done at the last trimester of pregnancy, but it does not indicate that the fetus should be delivered within 24 hours. Option B: If the score is 6, the health care provider will likely repeat the test within 24 hours. Option D: The test is most commonly done when there's an increased risk of problems that could lead to complications or pregnancy loss. The health care provider will determine the necessity and timing of a biophysical profile based on whether the baby could survive if delivered early, the severity of the mother's condition, and the risk of pregnancy loss.
A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? A. "I will need to have a full bladder for the test to be done accurately." B. "I should have my husband drive me home after the test because I may be nauseated." C. "This test will help to determine whether the baby has Down syndrome or a neural tube defect." D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."
Correct Answer: D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements. Option A: An ultrasound requires a full bladder. A full bladder creates a reservoir fluid that enhances the movement of sound waves through the abdominal cavity. This creates a clearer view of the structures that need to be observed. Option B: An amniocentesis is a test after which a pregnant woman should be driven home. Option C: A maternal serum alpha-fetoprotein test is used in conjunction with unconjugated estriol levels and human chorionic gonadotropin helps to detect Down syndrome.
Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? A. Notify the neonate's pediatrician immediately. B. Check the diaper and circumcision again in 30 minutes. C. Secure the diaper tightly to apply pressure on the site. D. Apply gentle pressure to the site with a sterile gauze pad.
Correct Answer: D. Apply gentle pressure to the site with a sterile gauze pad If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs. Option A: Immediate nursing intervention and assessment should be done first before notifying the physician. Option B: 30 minutes is a long time to reassess. Addressing the bleeding immediately may save it from getting worse. Option C: Tightening the diaper may elicit a case of diaper rash. Applying direct pressure on the bleeding site is more effective.
When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? A. Turn the neonate every 6 hours B. Encourage the mother to discontinue breastfeeding. C. Notify the physician if the skin becomes bronze in color. D. Check the vital signs every 2 to 4 hours.
Correct Answer: D. Check the vital signs every 2 to 4 hours While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights. Option A: Only one study reported the significance drop in serum bilirubin and shorter duration of phototherapy in the supine group. Keeping the jaundiced newborn in the supine position throughout phototherapy is as effective as turning them periodically based on appraised studies. Option B: The baby may be breastfed without interruption during phototherapy. Jaundice in breastfed babies is not a reason to stop breastfeeding as long as a baby is feeding well, gaining weight, and otherwise growing. Option C: Bronze baby syndrome is a rare complication seen in neonates with hyperbilirubinemia who are being treated with phototherapy. Affected neonates develop gray-brown skin, serum, and urine within a week of initiation of phototherapy.
A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first? A. Pad the side rails. B. Place a pillow under the left buttock. C. Insert a padded tongue blade into the mouth. D. Maintain a patent airway.
Correct Answer: D. Maintain a patent airway The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Option A: Padding the side rails should be done as a precaution before a seizure, not during the seizure. Option B: The client should be placed on a flat, firm surface to avoid any injuries. Option C: There should be nothing inserted inside the client's mouth to maintain airway patency and prevent obstruction and aspiration.
A client with type 1 diabetes mellitus who is a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus: A. Weekly fetal movement counts are made by the mother. B. Contraction stress testing is performed weekly. C. Induction of labor begins at 34 weeks' gestation. D. Nonstress testing is performed weekly until 32 weeks' gestation.
Correct Answer: D. Nonstress testing is performed weekly until 32 weeks' gestation For most clients with type 1 diabetes mellitus, non-stress testing is done weekly until 32 weeks' gestation and twice a week to assess fetal well-being. Option A: Increased fetal activity may minimize the impact of hyperglycemia on subsequent birth weight. The inactive fetus appears to be at a higher risk for glucose-mediated macrosomia. Option B: Contraction stress test may be done weekly with reassuring results of no heart rate deceleration in response to 3 contractions in 10 minutes. Option C: Nonstress test may be done twice a week with reassuring results of 2 heart rate acceleration in 20 minutes.
A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? A. Back B. Abdomen C. Fundus D. Perineum
Correct Answer: D. Perineum A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair. Option A: A spinal anesthetic is given into the middle of the lower back and local anesthetic is injected through the needle into the fluid that surrounds the spinal cord. It numbs the nerves that supply the abdomen, hips, bottom, and legs. Option B: General or regional anesthesia can be appropriate for patients undergoing abdominal surgery. Balanced anesthesia with inhalational anesthetics, opioids, and neuromuscular blockers are used in general anesthesia for abdominal surgical procedures. Option C: Spinal anesthesia is one of the most preferred anesthetic methods during Cesarean section since it provides easy and rapid induction, effective sensory and motor block, and has little effect on the fetus.
Which of the following would be inappropriate to assess in a mother who's breastfeeding? A. The attachment of the baby to the breast. B. The mother's comfort level with positioning the baby. C. Audible swallowing. D. The baby's lips smacking.
Correct Answer: D. The baby's lips smacking Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who's smacking his lips isn't well attached and can injure the mother's nipples. Option A: A good attachment shows much of the areola and the tissues underneath it, including the larger ducts, are in the baby's mouth; the breast is stretched out to form a long "teat", but the nipple only forms about one-third of the "teat"; the baby's tongue is forward over the lower gums, beneath the milk ducts; and the baby is suckling from the breast, not from the nipple. Option B: To be well attached at the breast, a baby and his or her mother need to be appropriately positioned. The mother can be sitting or lying down, or standing, if she wishes. However, she needs to be relaxed and comfortable, and without strain, particularly of her back. The baby can breastfeed in several different positions in relation to the mother: across her chest and abdomen, under her arm, or alongside her body. Option C: When the milk ejection reflex is triggered, the baby may swallow after every suck in order to handle the rapid flow of milk. You should hear suck, swallow, pause, suck, swallow, pause. Audible swallowing after every couple of sucks should continue for about ten minutes.
A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? A. Active phase B. Latent phase C. Expulsive phase D. Transitional phase
Correct Answer: D. Transitional phase The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. Option A: The active phase extends from 4 to 7 cm; it is moderate for the patient. Option B: The latent phase extends from 0 to 3 cm; it is mild in nature. Option C: The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.
A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time? A. Biophysical profile B. Amniocentesis C. Maternal serum alpha-fetoprotein (MSAFP) D. Transvaginal ultrasound
Correct Answer: D. Transvaginal ultrasound An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women, whose thick abdominal layers cannot be penetrated adequately with the abdominal approach. Option A: A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester. Option B: An amniocentesis is performed after the fourteenth week of pregnancy. Option C: A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal).
During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used to detect fetal anomalies? A. Amniocentesis B. Chorionic villi sampling C. Fetoscopy D. Ultrasound
Correct Answer: D. Ultrasound Ultrasound is used between 18 and 40 weeks' gestation to identify normal fetal growth and detect fetal anomalies and other problems. Option A: Amniocentesis is done during the third trimester to determine fetal lung maturity. Option B: Chorionic villi sampling is performed at 8 to 12 weeks' gestation to detect genetic disease. Option C: Fetoscopy is done at approximately 18 weeks' gestation to observe the fetus directly and obtain a skin or blood sample.
What are the four "P"'s of childbirth?
Power Passage Passenger Psyche
Risks associated with an amniocentesis:
Preterm Labor Preterm Premature Rupture of Membranes Infection Needle Injuries Miscarriage
Toxoplasmosis is an example of what type of teratogen? A. Environmental Pollutant B. Ionizing Radiation C. Maternal Disorder D. Maternal Infection
D. Maternal Infection
A nurse is assessing a 1-day postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the physician? a) Fundus at the umbilicus. b) Nodular breasts. c) Pulse rate 60 bpm. d) Pad saturation every 30 minute
D
Which action best explains the main role of surfactant in the neonate? A) Assists with ciliary body maturation in the upper airways B) Helps maintain a rhythmic breathing pattern C) Promotes clearing mucus from the respiratory tract D) Helps the lungs remain expanded after the initiation of breathing
D) Helps the lungs remain expanded after the initiation of breathingSurfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.
An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father? A. Suggest that his wife seek professional counseling to deal with her symptoms. B. Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D. Reassure him that normal maternal-fetal bonding is occurring.
D. Rationale: These behaviors are positive signs of maternal-fetal bonding (D) and do not reflect ambivalence (B). No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester. (A and C) are not necessary because the behaviors displayed are normal.
A woman who has autosomal dominant inherited disorder is exploring family planning options and the risk for transmission of the disorder to an infant. The nurse's response should be based on what information?
Each pregnancy carries a 50% chance of inheriting the disorder.
Why must the nurse carefully monitor the fetal heart rate following epidural administration?
Epidural anesthesia can cause hypotension, which will diminish placental perfusion and cause fetal distress.
True or False? The physiological changes of pregnancy will not effect a woman's response to medications.
False
What are the two powers of labor?
Uterine Contractions, Maternal Pushing
What is given to Rh negative mothers to prevent the development of maternal antibodies that cause hemolysis of of fetal Rh positive RBC's?
When the blood of an Rh-positive fetus gets into the bloodstream of an Rh-negative woman, her body will recognize that the Rh-positive blood is not hers. Her body will try to destroy it by making anti-Rh antibodies. These antibodies can cross the placenta and attack the fetus's blood cells. This can lead to serious health problems, even death, for a fetus or a newborn. During pregnancy, a woman and her fetus do not usually share blood. But sometimes a small amount of blood from the fetus can mix with the woman's blood. This can happen during labor and birth. It can also happen with amniocentesis or chorionic villus sampling (CVS) bleeding during pregnancy, attempts to manually turn a fetus to be head-down for birth (move the fetus out of a breech presentation), trauma to the abdomen during pregnancy. Health problems usually do not occur during an Rh-negative woman's first pregnancy with an Rh-positive fetus. This is because her body does not have a chance to develop a lot of antibodies. But if treatment is not given during the first pregnancy and the woman later gets pregnant again with an Rh-positive fetus, she can make more antibodies. More antibodies put a future fetus at risk. Rh immunoglobulin (RhoGAM) is a medication that stops the body from making Rh antibodies if it has not already made them. This can prevent severe fetal anemia in a future pregnancy. RhoGAM is administered at 28 weeks of pregnancy—A small number of Rh-negative women may be exposed to Rh-positive blood cells from the fetus in the last few months of pregnancy and may make antibodies against these cells. RhoGAM given at 28 weeks of pregnancy destroys these Rh-positive cells in the woman's body. This prevents Rh-positive antibodies from being made. RhoGAM is also given within 72 hours after the delivery of an Rh-positive baby—The greatest chance that the blood of an Rh-positive fetus will enter the bloodstream of an Rh-negative woman happens during delivery. RhoGAM prevents an Rh-negative woman from making antibodies that could affect a future pregnancy. The treatment is good only for the pregnancy for which it is given. Each pregnancy and delivery of an Rh-positive baby requires a repeat dose of Rho-GAM
What are some non-pharmacologic pain management techniques for labor?
relaxation hydrotherapy breathing techniques hydrotherapy hypnobirthing