Mastery Maternal Questions
A patient was recently discovered to have an ectopic pregnancy. The nurse should tell the patient which of the following?
"Most women who have an ectopic pregnancy have normal pregnancies and births in the future." "Ectopic pregnancy can be either medically or surgically treated." • Ectopic pregnancies can be managed either surgically or medically. Ectopic pregnancies are rarely viable. A ruptured ectopic pregnancy requires surgery to repair or remove the affected fallopian tube. If the ectopic pregnancy is unruptured, medical intervention is done to minimize damage and prevent rupture. • Most women go on to have uncomplicated pregnancies and births in the future, though around 10% may have another ectopic pregnancy. After surgical treatment, most physicians will recommend waiting 3-6 months before trying to conceive again. • An ectopic pregnancy is one in which implantation occurs outside the uterine cavity. Immediately after the union of ovum and spermatozoon, the zygote begins to divide and grow normally. Unfortunately, the zygote does not travel the length of the tube to reach the uterus. It implants into the lining of the fallopian tube instead of the uterine wall. • Medical treatment involves oral administration of Methotrexate followed by leucovorin. Methotrexate, a folic acid antagonist chemotherapeutic agent, attacks and destroys rapidly-dividing, fast-growing cells. • As the fetus grows in the fallopian tube, there is a tendency to rupture. If a tube is removed, the woman's fertility is reduced because while she will still ovulate, the eggs released from the affected side cannot be fertilized or reach the uterus without a fallopian tube. Ovulation alternates between the left and right ovaries, so pregnancy can only take place every other month when an egg is released from the unaffected side.
A woman receives a rubella vaccination while in the hospital. Which of the following instructions would the nurse give her?
"You can receive this vaccine while breastfeeding." "Wait at least 28 days before becoming pregnant." • The rubella vaccine should not be administered to women who are pregnant or plan on becoming pregnant within 28 days. There is a theoretical possibility that the infant could contract congenital rubella syndrome. The patient should be instructed to use effective birth control for at least 28 days. • The rubella vaccine may be given to women who are breastfeeding. • Hypersensitivity to eggs is no longer a contraindication to the rubella vaccine. • It is not necessary for the woman to avoid contact with others. • The patient does not have to refrain from eating eggs unless she has a history of anaphylaxis with eggs.
Methylergonovine has been ordered for a postpartum patient. The nurse should withhold this drug when which of the following is present?
Blood pressure of 170/95 mmHg • Methylergonovine (Methergine) is ordered to prevent postpartum hemorrhage. However, Methergine can cause hypertension by vasoconstriction. It is important to obtain a baseline blood pressure before administering the drug. • Methergine should not be given to a woman with an elevated blood pressure. • Methylergonovine administration is sometimes necessary up to 8 hours after birth to promote uterine contraction to prevent postpartum hemorrhage. If the uterus suddenly relaxes, there may be an abrupt gush of blood from the placental site. • Incorrect: Increased uterine blood flow will increase the risk of severe hemorrhage, so this is not a contraindication. • Incorrect: Pulse of 89 is within normal limits. Temperature of 100.1 should be reassessed after 15 minutes. A slight increase in temperature might happen if the woman is confined in a humid environment. • Incorrect: The woman should be informed that tender breasts after birth are considered normal because the breasts begin to engorge to prepare for lactation.
The nurse is educating a new mother about the dangers of sunburn for her 3-month-old infant. Which of the following is the best advice?
"Babies under 6 months old should be kept out of the sun as much as possible." "Sunscreen should not be used on infants younger than 6 months." • Infant's skin is very sensitive to the sun. Therefore, they should be kept out of the sun until six months of age. • Sunscreen should not be used until the infant can be out in the sun.
The nurse is assessing a patient's blood pressure during labor. The patient asks why her blood pressure is measured so frequently. Which of the following should the nurse say?
"Blood pressure changes may affect the fetus." "Following the blood pressure changes allows us to track your contractions." "Blood pressure changes can be a side effect of the medications you have been given." • Correct: "Blood pressure changes may affect the fetus." Frequent blood pressure monitoring is needed because changes in blood pressure can affect fetal blood supply. • Correct: "Following the blood pressure changes allows us to track your contractions." Monitoring of contraction intensity and duration is aided by monitoring of blood pressure to recognize when a patient is having a contraction, even when she may not feel it (if she has an epidural). • Correct: "Blood pressure changes can be a side effect of the medications you have been given." Many of the medications given in labor affect blood pressure and this should be explained to the patient.
During labor, a patient was observed to have thick, green-colored amniotic fluid when her membranes ruptured spontaneously. Soon after the birth of her baby, the neonate had difficulty establishing respirations, appeared cyanotic, and had tachypnea and retractions. The nurse understands which of the following is a priority intervention for the neonate?
Intubating the infant and suctioning the meconium. • When meconium aspiration occurs, intubation and immediate suctioning of the airway for no longer than 5 seconds is indicated. If heart rate is low, positive pressure ventilation is administered and suctioning is performed again later. • If the infant has normal respiratory effort, tone, and heart rate over 100, intubation is not done and meconium is cleared from the mouth and nose with a bulb syringe or suction catheter. • It was once recommended that the infant be suctioned by a bulb syringe as soon as the head is delivered, but the American Academy of Pediatrics no longer recommends this. • Do not administer oxygen under pressure until the infant has been intubated and suctioned. This is so the oxygen pressure does not drive small plugs of meconium farther down into the lungs. • After tracheal suction, infants may be treated with oxygen administration. Antibiotic therapy may be used to prevent the development of pneumonia.
What should the nurse assess before administering magnesium sulfate to a 20-year-old primipara with pregnancy-induced hypertension?
Urine output Respiratory rate Deep tendon reflex Blood pressure
A patient comes to the clinic stating that she may be pregnant. The nurse knows that a pregnancy can be confirmed by
ultrasound fetal visualization • There are only three positive signs that are used to confirm pregnancy: fetal heart sounds heard by doppler ultrasound, ultrasound visualization of the fetus, or fetal movements palpated by the examiner.
A newlywed is experiencing amenorrhea, nausea and vomiting. She consults a physician and finds out that she is pregnant. The patient is very excited and at the same time feels afraid of the impending situation of her pregnancy. What psychological state of pregnancy has the patient achieved?
Accepting the Pregnancy • Accepting the pregnancy involves recovering from the shock of learning they are pregnant and concentrating on what it feels like to be pregnant. A common reaction is ambivalence, or feeling both positively and negatively toward the pregnancy. • As many as 50% of pregnancies are unintended, unwanted, or mistimed. Every pregnancy is a surprise to some extent, either because the woman had not planned on becoming pregnant or had been looking forward to being pregnant but cannot believe it has happened.
A patient with an epidural catheter receives an opioid as needed for pain. After inspecting the insertion site but before administering the opioid, which of the following should the nurse do first?
Aspirate with the syringe. • Before administering a medication via epidural catheter, the nurse should aspirate. Aspiration of clear fluid under 1 ml confirms correct epidural catheter placement. • NOTE: Aspiration of bloody fluid or clear fluid greater than 1 ml indicates the catheter may be outside the epidural space. If this happens, the nurse should notify the physician immediately.
A patient in labor is being monitored for contractions. In order to document the patient's uterine activity before, during, and after each contraction, which of the following must the nurse document?
Contraction duration Contraction frequency Contraction intensity • The nurse needs to document uterine activity before, during, and after contractions. This includes the frequency (how often), intensity (how intense, firmness), duration (time from start to finish), and also uterine resting tone following contractions. • Although contraction characteristics do not always correlate with labor progress, nurses are responsible for monitoring and describing uterine contractions in order to detect whether they have characteristics needed to expel the fetus, and also to detect abnormal uterine activity. • Monitoring contractions can be accomplished by palpation methods, maternal subjective reporting, external electronic monitoring, or internal monitoring, with varying degrees of accuracy, depending on the method used. • Dilation of the cervix should be documented at appropriate intervals but is not always included when documenting uterine contractions. • Patient position can affect the length of labor, and this should be documented in the patient's chart, but this is not related to documenting uterine activity.
A woman who has been in labor for 6 hours is now 9 centimeters dilated and has intense contractions every 1 to 2 minutes. She is anxious and feels the need to bear down with her contractions. What is the best action for the nurse to take?
Encourage panting through contractions to prevent pushing. • Because the woman has not reached full cervical dilatation, which is 10 centimeters, it is best for the nurse to encourage the woman to breathe using repeated, short puffs to delay pushing while allowing her cervix time to reach full dilation. • Allowing the woman to push without a fully dilated cervix will predispose her to bleeding and cervical lacerations. • By this time, the woman has already reached the transition phase of the first stage of labor. The contractions have reached their peak of intensity, occurring every 1 to 2 minutes. A woman in this phase may experience intense discomfort so strong that she may also experience a feeling of loss of control, anxiety, panic, and irritability. • Incorrect: During the first stage of labor, it is best to position the woman in the left side lying position. This position causes the heavy uterus to tip forward, away from the vena cava, allowing blood return from the lower extremities and adequate placental filling and circulation. • Incorrect: During the transition phase, the woman often becomes irritable and restless. The patient may resist being touched and push away.
A nurse is caring for a three-day-old infant with hyperbilirubinemia who is receiving phototherapy. Which of the following nursing actions would be appropriate?
Feed the infant every 2 hours. Keep the eyes and genitalia covered throughout therapy. Allow the parent to hold the infant to promote bonding. • An infant's liver struggles to process bilirubin because the mother's circulation does this for the fetus. Upon birth, exposure to light triggers the liver to assume this function. Additional light speeds up the conversion potential of the liver. • An infant receiving phototherapy should be removed from under the lights for feeding so that she/he continues to have interaction with the mother. • Remove the eye patches during the time the infant is with the mother to give the infant a period of visual stimulation. • Swaddling the infant is inappropriate. The infant receiving phototherapy must be exposed to the light. Only eyes and genitalia should be covered.
To accurately assess for jaundice in a patient with dark skin, the nurse should examine which area of the body?
Hard palate of the mouth Sclera closest to the iris Soles of the feet • Jaundice is best assessed in the sclera. However, the dark-skinned patient may normally have yellow pigmentation in the sclera, so assess the area closest to the iris, not the corners of the eye. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. • Jaundice can also be assessed on the soles of the feet in a patient with dark skin. • Cyanosis is best observed in the nail beds. • Skin on the palm of the hand can indicate jaundice, but skin on the back of the hand cannot.
A new mother is interested in seeing what her infant's eyes look like. Which is the most effective way for the nurse to stimulate the infant to open its eyes?
Hold the infant in an upright position. • When held upright, an infant will open the eyes reflexively. • Incorrect: Separating the eyelids causes the eyes to close due to the blink reflex. • Incorrect: Moro reflex also causes the eyes to close. • Incorrect: Infants are sensitive to light and will close their eyes in the presence of a bright light.
A newborn's lab result indicates a phenylketonuria (PKU) level of 30 mg/dl. What should the nurse do next?
Immediately notify the physician of the critical test result. • A normal PKU is less than 2 mg/dl. • A PKU level of 30 mg/dl is critically elevated and should be communicated to the physician immediately to provide early intervention. • Phenylalanine is an amino acid normally present in the body. This test is done to check whether the baby has an enzyme needed to change phenylalanine into tyrosine. Without it, the phenylalanine level builds up in the body, causing brain damage, microcephaly, and cerebral impairment.
A patient with a history of hypertension in pregnancy calls the hospital complaining of a severe headache and blurred vision. How should the nurse respond?
Tell the patient to hang up and call 911 immediately. • Pregnancy-induced hypertension (PIH), also called preeclampsia, must be monitored closely. Symptoms of worsening PIH include sudden weight gain, swelling or edema, severe headache, reports of seeing spots, blood in the urine, dizziness, or nausea and vomiting. • When preeclampsia worsens during pregnancy, the baby may need to be delivered or magnesium may need to be given intravenously to prevent seizures. • The patient needs to call 911 to be evaluated and, if necessary, treated immediately to reduce her blood pressure and prevent complications. • Pregnancy-induced hypertension can last for several weeks after delivery, and mothers may return home with by-mouth medications to control blood pressure.
A primipara patient who takes prenatal vitamins daily asks the nurse the etiology of her physiological anemia. The nurse replies that in physiological anemia of pregnancy, lower hemoglobin and hematocrit is due to
increased plasma volume • To provide an adequate exchange of nutrients in the placenta and to compensate for blood loss at birth, the circulatory blood volume of the woman's body increases at least 30% during pregnancy. Although red cell mass also increases, plasma volume increases more, causing hemodilution and a lower hemoglobin and hematocrit. • The increase in blood volume occurs gradually near the end of the first trimester. It peaks at about the 28th to the 32nd week and continues at this high level through the third trimester. • Iron absorption may be impaired during pregnancy as a result of decreased gastric acidity, and additional iron is often prescribed during pregnancy to prevent true anemia, but physiologic anemia is seen in most women simply due to hemodilution.
While caring for a one-day-old newborn, the nurse performs her morning assessment. When assessing the chest comparatively to the head, she would expect
the chest circumference to be about 2 cm less than the head circumference • The chest circumference in a term newborn is usually about 2 cm less than the head circumference. • Chest circumference is measured at the level of the nipples. If edema of the breasts is present, this measurement will not be accurate until the edema has subsided. • A mature newborn with a head circumference greater than 37 cm or less than 33 cm should be carefully investigated for neurologic involvement.
A newborn less than 3 hours old has a split S2 that is heard on inspiration and a HR of 140 beats/minute. What should the nurse do next?
• A split S2 on inspiration is a normal finding for newborns during the first few hours of life. All the nurse needs to do at this point is to document the finding. • Normal HR for newborns is 120 to 160 beats/minute. • There is no need to notify the physician or inform the parents of a normal finding. • Assessing the newborn's neurological status is not needed based on the scenario.
A pregnant woman is rushed to the hospital with vaginal bleeding, rapid thready pulse, and falling blood pressure. She is distressed and crying. After inserting a needle through the postvaginal fornix, the doctor confirmed a ruptured ectopic pregnancy. The nurse's immediate action prior to surgery is to
• Once an ectopic pregnancy ruptures, it is an emergency situation and the woman's condition must be evaluated quickly. Keep in mind that the amount of blood evident is a poor estimate of the actual blood loss. • Use the A-B-C Framework to answer this question. This patient is crying and does not have evidence of a compromised airway but is hemorrhaging, so your initial intervention should address the bleeding. • To keep blood to the vital organs, immediately position the patient in the Trendelenburg position with the feet higher than the head. After positioning the patient, intravenous fluids are administered using a large-gauge catheter to restore intravascular volume. Blood can be administered through this same line.
A patient is having trouble adjusting to breastfeeding and disagrees with her husband on the importance of breastfeeding compared to formula. Which member of the health care team should the nurse consult?
Lactation consultant • Lactation consultants are professional breastfeeding specialists who can help with breastfeeding problems such as latching difficulties, poor milk supply, or trouble with pumping. They can provide education about the benefits of breastfeeding as well as troubleshooting problems during the adjustment period. • A lactation consultant is trained to answer questions about breastfeeding and can best discuss these issues with the patient and her husband.
A 30-year-old primipara is administered an epidural anesthesia. During the first hour of post-epidural anesthesia administration, which of the following signs and symptoms should be referred immediately to the anesthesiologist?
Respiratory distress • Epidural anesthesia can cause serious and potentially life threatening complications. Safe and effective management requires a coordinated multidisciplinary approach. Respiratory depression can result if opioids are used. • Side effects of epidural opioids may include nausea and vomiting, pruritus, and delayed maternal depression. The possibility of late respiratory depression exists for up to 24 hours after the administration of an epidural opioid, depending on the duration of action of the drug used. Epidural provides pain control during much of labor and for birth itself. • Regional pain control methods may be used for intrapartum analgesia, surgical anesthesia, or both. These methods provide pain relief without loss of consciousness.
A 34-year-old pregnant woman is in the clinic for her first-trimester checkup. While assessing the patient's health history, the nurse should be most concerned about which of the following?
• Taking over-the-counter medications can be dangerous during pregnancy. Many common drugs are teratogenic. The fetus is at a high risk of developing deformities during the first trimester.
What should the nurse document when a physician places a direct fetal scalp electrode?
• This is the most reliable way to measure FHR. • When a fetal scalp electrode is placed by a physician, the nurse should document the time of placement, the physician applying the electrode, and the FHR.
A patient with mastitis asks the nurse if her infant will be infected if she continues to breastfeed. Which of the following is the appropriate response by the nurse?
"Continue breastfeeding because the bacteria is localized in the breast tissue and will not enter the breast milk." "You will want to stop breastfeeding if an abscess forms." • Breastfeeding is continued because frequent emptying will help prevent the growth of bacteria. Complete emptying of breasts prevents stasis of milk and engorgement. This aids in reducing the risk of further infection and pain. • The organism causing the infection usually enters through cracked or fissured nipples. The bacteria remain localized in the breast tissue and will not enter the breast milk. • Discontinue breastfeeding if the breast infection is untreated and forms an abscess. However, the woman is encouraged to continue to pump breast milk until the abscess has resolved so she can continue breastfeeding again after treatment. • The woman, not the infant, will be placed on a broad-spectrum antibiotic. • Breastfeeding has major physiologic advantages for the infant. Breast milk contains secretory immunoglobulin A, which provides the infant with additional immunity.
A patient has been prescribed oral contraceptives. Which statement by the patient indicates the need for further education?
"Once I start this medication, I don't need to use condoms." • The patient should be instructed to use a backup method of birth control for the first 7 days of taking oral contraceptives to prevent pregnancy. The patient should also be educated about the continued risk of sexually transmitted infections. • The statements about taking the pill at the same time every day, the pill not protecting against sexually transmitted infections, and needing to take the pill every day are all correct.
A nurse is caring for a patient in need of birth control. The patient questions the nurse about the diaphragm. Which of the following is correct?
"The diaphragm should be left in place for 6 hours after intercourse." "The diaphragm is recommended for monogamous women." "Spermicide is needed." • Acting as a reservoir for spermicide, the diaphragm must be left in place for 6 hours after intercourse to be effective. • Spermicide is used with the diaphragm. • Removing the diaphragm immediately after intercourse will decrease its effectiveness. • The diaphragm is recommended for monogamous women because it does not protect against STDs, only pregnancy. • Having the diaphragm in place at all times is not recommended.
A nurse is teaching the parents of a newborn proper post-circumcision care. Which of the following statements should the nurse say?
"The patient cannot be discharged until after voiding." "Lubricating ointment should be applied to the penis after each diaper change." "Two to five days of site care is required after discharge." • The nurse should prepare the parents of the infant for discharge, which can happen after the infant has voided. • The parents should anticipate 2 to 5 days of regular site care after discharge. Lubricating ointment should be applied to the penis after each diaper change. • A small amount of bleeding is a normal finding after a circumcision. Parents should report a large amount of blood (i.e area of blood larger than a quarter). • Cleaning the site with alcohol is not recommended because it would interfere with healing by drying the skin and possibly causing pain. Instead, a soft washcloth and warm water should be used to clean the baby's penis. Mild soap is okay if the baby's penis has stool on it.
Courtney, a 34-year-old, suspects that she is pregnant. A serologic immunoassay test is performed to determine if she is pregnant. Which of the following statements is true about the test?
A blood specimen must be used. It is highly accurate by 8-10 days after conception. This test can be used to indicate how developed the embryo or fetus is. • All serology pregnancy tests are designed to detect human chorionic gonadotropin (hCG), which is a glycoprotein hormone secreted by the developing placenta shortly after fertilization. In a normal pregnancy, a qualitative serologic test detects the presence of the hCG hormone found in the serum and urine of pregnant women just 7-10 days following fertilization. • The appearance of hCG in urine soon after conception and its subsequent rise in concentration during early gestational growth make it an excellent marker for the early detection of pregnancy. Even some over the counter home pregnancy urine tests can detect as little as 6.3 mIU/mL of hCG in urine, an amount which varies widely, but may be present anywhere from 3-9 days before a missed period. • A quantitative immunoassay test measures the concentration of hCG, indicating the age of the baby. This test also screens for abnormalities that would give an abnormal hCG level like ectopic pregnancies, molar pregnancies, or possible miscarriages. • Random urine specimens are appropriate for urine hCG testing (not serologic), but the first-morning urine is optimal because it generally contains the highest concentration of hCG. • Serologic tests require a blood sample, not urine. • Over-the-counter urine tests (not serologic tests) can give false negatives because any low result will be negative, which can mean simply that the embryo has not yet implanted or developed enough to produce the minimum amount of hCG to meet the sensitivity requirements of the test.
A nurse is providing care to a woman who is 38 weeks pregnant. During the most recent vaginal examination, the nurse notes the cervix is 6 centimeters dilated and 100% effaced, with the vertex at -1 station. Based on this examination, what is the best interpretation?
Active labor with the head as presenting part, not yet engaged • The best interpretation is that the woman is in active labor with the head as presenting part. This is because cervical dilation is 6 centimeters and not yet engaged (i.e., the vertex lies at -1 station). • Incorrect: Transition phase refers to the time when the cervix is dilated from 8 to 10 centimeters. • Incorrect: Latent phase is when cervical dilatation begins, but this patient is already at 6 centimeters dilated. • Incorrect: Active labor, fully engaged is incorrect because the woman is still at -1 station or not yet engaged.
The nurse assesses a postpartum patient as having moderate lochia rubra with clots on her second postpartum day. Which of the following interventions would be appropriate?
Assess the fundus and bladder status • Lochia rubra is a postpartum vaginal discharge consisting almost entirely of blood. There are often small particles of deciduas and mucus during the first 3 postpartum days. This is expected. • There is no complication or any signs of postpartum hemorrhage. • During birth, the fetal head exerts pressure on the bladder and urethra as it passes on the bladder's underside. This pressure may leave the bladder with a transient loss of tone. To prevent permanent damage to the bladder from over-distention, assess the woman's abdomen frequently. • To assess involution process (the shrinking of the uterus after the birth), the nurse should palpate the fundus to see if it is firm and well-contracted. • Incorrect: Methergine should not be given because the woman is in her second postpartum day and has a normal lochia as expected. • Incorrect: The other intervention choices are inappropriate because the woman is not suffering from blood loss.
A nurse performs an initial assessment on a neonate. The neonate has a heart rate of 130 beats/minute and is gasping for air. The neonate has blue extremities and is moving vigorously. When stimulated, the infant only grimaces. What should the nurse do next?
Assign an Apgar of 7, place the patient in modified Trendelenburg, and apply oxygen. • The patient's Apgar score is 7. The patient is in respiratory distress and is having trouble oxygenating her extremities. Placing the patient in modified Trendelenburg will ensure adequate blood flow to her brain and vital organs. Heart rate of 130 beats/minute: 2 pts Gasping for air: 1 pt Blue extremities: 1 pt Moving vigorously: 2 pts When stimulated, the neonate only grimaces: 1 pt • The patient does not need resuscitation. Apgar scored from 0 to 10. Each category is scored 0 to 2. • Appearance: Blue/pale all over, blue extremities/pink body, entire body pink • Pulse: Absent, <100 bpm, >100 bpm • Grimace: No response to stimulation, grimace/feeble cry, cry or pull away • Activity: None, some flexion, flexed extremities that resist extension • Respiration: Absent, weak/irregular/gasping, strong cry
A premature neonate is experiencing severe respiratory distress in the delivery room. Once bag/mask ventilation and oxygen are provided, the condition of the infant deteriorates further. The abdomen appears sunken, body temperature is low, cyanotic and nasal flaring are observed. Which action should the nurse prepare for next?
Assisting the physician with endotracheal intubation. • For premature infants, respiratory distress syndrome can be largely prevented by the administration of synthetic surfactant through an endotracheal tube. The nurse should be prepared to assist the physician with this procedure. Ventilations are pressure-cycled to control the force of the air delivery. • Pancuronium is a muscle relaxant that may be given during endotracheal intubation and can increase pulmonary blood flow. • The infant is suctioned before surfactant administration. After administration, the infant's airway should not be suctioned again for as long as possible to avoid suctioning out the surfactant. • A possible complication of oxygen therapy in the immature or very ill infant is retinopathy of prematurity or bronchopulmonary dysplasia.
The nurse is caring for a newborn who has undergone PlastiBell circumcision. What is the priority nursing action to minimize the risk for complications?
Check for bleeding every 15 minutes for the first hour. • Complications that can occur after circumcision include hemorrhage, infection, and urethral fistula formation. • To keep the risk of complications to a minimum, the first priority of the nurse is to monitor the infant for bleeding every 15 minutes for the first hour after the procedure. • For the first 3 days, parents should be taught how to keep the area clean and covered until the healing is complete. A film of yellowish mucus often covers the glans by the second day after surgery, which is normal. Instruct parents to check the area often for redness, be alert to constant crying that may be due to pain, and monitor for foul odor or fever that may indicate infection. • It is also important to document when the infant voids after circumcision, but this is secondary. • Normally, circumcision sites appear red and will be tender, but they should never have a strong odor or discharge. • Petroleum jelly should not be applied after circumcision when a PlastiBell is used.
A newborn has been admitted to the nursery shortly after birth. Nursing assessment reveals all of the following findings. Which findings should the nurse consider abnormal?
Depressed fontanelles Visible jaundice • Jaundice during the first 24 hours after birth is always considered pathologic. Jaundice occurring after 24 hours lasting to day 8 is normal for term infants. • Jaundice occurs due to an increase in serum bilirubin. This occurs in newborns because of several factors, including low enzyme activity used for the conversion and excretion of bilirubin, shorter life span of red blood cells, and low levels of intestinal flora resulting in high absorption rates of bilirubin. • Sunken or depressed fontanelles in a newborn would indicate dehydration or low fluid volume and are a finding that should be reported to the physician. • The other options are considered normal in the newborn. Just after birth, the newborn typically can have cyanotic extremities. Acrocyanosis is a finding seen in healthy newborns, affecting the hands, feet, and mouth caused by vasomotor changes that cause vasoconstriction peripherally. This can last for 24-48 hours! As the newborn adjusts to life outside the uterus, this resolves.
The nurse is assessing a newborn's reflexes. Which of the following best describes the Babinski reflex?
Dorsiflexion of the great toe when the sole is scratched • The Babinski reflex is characterized by dorsiflexion of the great toe and fanning of the other toes when the sole of the foot is stimulated. This reflex normally disappears after 24 months. • In adults, the normal plantar reflex causes plantar flexion of the great toe. • When the Babinski reflex is present in adults and in children over the age of 24 months, it may indicate damage to the pyramidal tracts.
A patient is admitted to the hospital to deliver through labor induction. The nurse administers oxytocin as ordered by the physician. Knowing the potential complications of oxytocin, which of the following should the nurse monitor closely?
Fetal heart rate • Oxytocin stimulates strong uterine contractions that can cause decreased fetal heart rate and hypoxia due to increased uterine pressure. The nurse should closely monitor the fetal heart rate for any changes. • Incorrect: Although it is important to monitor cervical dilation, maternal heart rate, and maternal neurological status, fetal heart rate is the most critical assessment to monitor when giving oxytocin.
The nurse cares for a postpartum patient. Which of the following signs suggest endometritis?
Foul-Smelling Lochia Cramping Uterine tenderness • Endometritis is an infection/inflammation of the endometrium (lining of the uterus). It can occur during pregnancy or after childbirth or it may occur unrelated to pregnancy (when it is called pelvic inflammatory disease). • Endometritis may be caused by organisms that are normal inhabitants of the vagina and cervix; however, organisms such as gonorrhea and chlamydia may be frequently encountered during pregnancy. If left untreated, these infections may lead to postpartum endometritis and a potential for maternal and/or neonatal morbidity. • Major signs and symptoms of endometritis are fever, chills, malaise, lethargy, anorexia, abdominal pain, and cramping, uterine tenderness, and purulent, foul-smelling lochia. • The nurse should expect treatment of the organism according to CDC guidelines if indicated. • Constipation and hemorrhoids are common postpartum complications but are unrelated to endometritis. Cramping Constipation Uterine tenderness
The nurse is caring for a woman in labor. What signs or symptoms would indicate that the patient is in the transition stage of labor?
Increased irritability Complaints of nausea Has heavier show • During the transition phase of the first stage of labor, the maximum cervical dilation of 8 to 10 cm occurs, and contractions reach their peak of intensity and occur every 2 to 3 minutes at a duration of 60 to 90 seconds. • During the transition phase, the woman may experience intense discomfort so strong it is accompanied by nausea and vomiting. Because of the intensity and duration of the contractions, she may experience a feeling of loss of control, anxiety, panic, and irritability. Since dilatation continues at a rapid rate, the membranes rupture and heavy show is present. • Uncontrollable urge to push or bear down and bulging at the perineum are signs of the second stage of labor.
During the first prenatal visit, a patient reports that the first day of her last menstrual cycle was October 16. Based on Naegele's rule, the nurse determines the expected day of delivery for the patient is
July 23 of the next year • According to Naegele's rule, you have to subtract 3 months and add 1 year and 7 days from the first day of the last menstrual period.
The nurse is assisting a patient who just delivered a healthy baby boy weighing 3,400 grams. Upon cord traction of placenta, the nurse notices a sudden gushing of a large amount of blood, and the fundus is no longer palpable in the abdomen. What are useful nursing interventions if uterine inversion is suspected?
Leaving the placenta in place Assessing vital signs Discontinuing uterotonic drugs Establishing IV access and fluids • Never attempt to remove the placenta if it is still attached, as this will only create a larger surface area for bleeding. • When an inversion occurs, a large amount of blood suddenly gushes from the vagina. The fundus is not palpable in the abdomen. If the loss of blood continues unchecked, the woman will immediately show signs of blood loss. • Uterine inversion may occur after the birth of the infant if traction is applied to the umbilical cord too soon or if pressure is applied to the uterine fundus when the uterus is not contracted. • Administering an oxytocic drug only compounds the inversion. • Uterotonic drugs should be discontinued to allow uterine relaxation for replacement. • IV fluids should be commenced to support blood pressure.
The nurse is assessing a patient after delivery and finds the uterine fundus boggy and 1 centimeter above the umbilicus. Which of the following is the priority nursing intervention?
Massage the uterus • Using the A-B-C Framework, the nurse skips airway and breathing and moves to an intervention to control bleeding in this situation. • If there is uterine atony, the first priority intervention of the nurse is to control hemorrhage by attempting uterine massage to encourage contraction. This stimulates uterine contraction, which compresses the vessels and reduces blood flow. • Incorrect: Second priority is to notify the physician if the uterus remains uncontracted. The physician will order oxytocics to help the uterus maintain tone. • Incorrect: When the uterus is firm, observe the perineum for passage of clots and blood. • Incorrect: Assess vital signs after ensuring that the uterus is well-contracted.
A patient has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12 and fetal bradycardia is present. Based on these findings, the nurse should take which action?
Prepare for a Cesarean Section • Infants with meconium-stained amniotic fluid may have respiratory difficulties and bradycardia at birth. • Based on the assessment, fetal metabolic acidosis is present. These findings pose a great threat to the newborn's well-being. A cesarean section is required. • Incorrect: Amnioinfusion is an infusion of sterile isotonic solution into the uterine cavity during labor to reduce umbilical cord compression. This is also done to dilute meconium in the amniotic fluid, reducing the risk that the infant will aspirate thick meconium at birth. This procedure is not sufficient in this scenario.
A woman is completely dilated and at +2 station. Her contractions are strong and last 50 to 70 seconds. Based on this information, the nurse should know the patient is in which stage of labor?
Second stage of labor • This woman has already reached full cervical dilation and already lies at +2 station. The nurse should anticipate caring for this mother in the second stage of labor. • The presenting part is now below the ischial spines. As the fetal head touches the internal side of the perineum, the perineum begins to bulge and appear tense. The circle enlarges until the fetus is pushed out of the birth canal. • Incorrect: The first stage of labor is incorrect because the first stage of labor starts from the onset of regularly perceived uterine contractions and ends with full cervical dilation. • Incorrect: Third stage of labor, or the placental stage, follows after the expulsion of the infant and ends with the delivery of the placenta. • Incorrect: The fourth stage of labor is incorrect because the fourth stage follows placental expulsion to 1 to 4 hours postpartum.
A patient was transported to the post-anesthesia care unit (PACU) after a cesarean section. The PACU nurse was informed that the patient received epidural anesthesia for the procedure. What is the safest position for this patient?
Semi-Fowler's position • Post-operative patients who have received epidural anesthesia must be positioned in semi-Fowler's position to prevent upward migration of the opioid in the spinal cord. This decreases the risk for respiratory depression associated with epidural anesthesia. • The other options are inappropriate positions for these patients.
A pregnant woman is expecting to deliver in two months. She expresses concern about the immunization schedule for her upcoming baby, particularly the hepatitis B vaccine. What information should be explained to the patient?
The child should receive a second dose of the hepatitis vaccine one month after the first dose and a third dose when the child is six to 18 months old. The first dose of hepatitis B vaccine for infants should be administered at birth. • The first dose of the hepatitis B vaccine is usually administered at birth, but it can also be given within the first two months of life. The second dose should be given one month after the first dose. The third dose must be given when the child is between 6 and 18 months old. • Hepatitis B vaccine is not effective if the infant is already infected with hepatitis B. The vaccine is intended to prevent the hepatitis B infection, but it is not used as a curative agent in the presence of infection. • If an infant is born to an infected mother, hepatitis B can be prevented if the infant receives hepatitis B immune globulin and the first dose of the hepatitis B vaccine within 12 hours of birth. • The vaccine must be directly administered to the infant, not the mother. • Breast milk offers many benefits, but it does not protect an infant from hepatitis B.
Which of the following of Leopold's maneuvers should the nurse use to determine if the presenting part of the fetus is engaged?
Third maneuver • The first maneuver determines the fetal part lying in the fundus and the fetal presentation. • The second maneuver determines which direction the fetus's back is facing. • The fourth maneuver determines the fetal attitude and degree of flexion of the fetal head. • The third maneuver determines the part of the fetus at the inlet and its mobility. If the presenting part moves upward so an examiner's hands can be pressed together, the presenting part is not engaged.
After performing Leopold's maneuvers on a patient in labor, the nurse should prepare the patient for a vaginal delivery after determining if the fetus is in which of the following positions?
Vertex presentation • The vertex presentation is the most favorable presentation for normal vaginal birth. The fetus's head is the first part to contact the cervix, and the fetus' long axis is parallel with the long axis of the mother. • Incorrect: Transverse lie (sideways position) poses a difficult presentation for a vaginal birth. This would put both the mother and child in jeopardy. It is advisable to have a cesarean section because the fetus is lying horizontally in the pelvis. • Incorrect: Oblique lie (diagonal position) is a situation in which the long axis of the fetal body crosses that of the maternal body. If the fetal lie is not in line with the mother's spine, a cesarean section may be required. • Incorrect: In face presentation, the fetus has extended its head to make the face the presenting part. The presenting diameter is so wide that vaginal birth may be impossible.
A nurse is preparing to bathe a full-term newborn for the first time since birth. Which of the following should the nurse do?
Wait until the newborn's vital signs are stabilized. Wait until the newborn's temperature has stabilized, and give the bath under a radiant heat source. Wear gloves when handling the newborn until after the bath is given. • The newborn's vital signs should be stable to prevent complications. • The newborn's body temperature should be at least 36.5° C (97.7° F), and the sponge bath should be given under a radiant heat source to prevent excessive heat loss. • Gloves should be worn when assessing or caring for a newborn before the first bath to prevent exposure to bloodborne pathogens. Standard Precautions require handwashing before any infant care, but gloves are to be worn if there is risk of contact with body fluids (such as with diaper changes or circumcision care). • Medicated soap and scrubbing can irritate the newborn's skin and cause abrasions. • The nurse does not need to wait until the newborn's first void.
A patient is near completion of the fourth stage of labor for a vaginal delivery. The labor and delivery nurse calls report to the unit nurse and includes the following information: temperature 37.2°C, heart rate 58, WBC count 16,000. How should the receiving nurse respond?
You can transfer the patient whenever you're ready. • The fourth stage of labor describes the time from one hour after birth to four hours after delivery when the tone of the uterus is restored with continued contractions from the release of oxytocin. Based on the given assessment, this patient has a heart rate within normal limits for an adult, acceptable labs, and is afebrile. • Maternal assessments during the fourth stage of labor should occur every 15 minutes for the first hour, and then every 30 minutes for the second hour. If regional anesthesia has been used, additional assessments are required. A woman should never be discharged from the recovery area until completely recovered from anesthesia. • Routine assessments include: Blood pressure and heart rate and regularity Temperature Fundus Bladder (for distention) Lochia (small to moderate) Perineum • In the third stage of labor, after the placenta is expelled (usually 5 to 30 minutes after the birth), maternal bleeding, vital signs, and the fundus are assessed. • In the fourth stage of labor, the blood pressure and pulse are expected to return to pre-labor levels. Normal heart rate for most adults is generally 60 to 100. Heart rate can vary with age, size, and fitness level, so it is most important to determine if this heart rate is normal for this patient. Uterine massage may be needed, and ice packs can be given for perineal comfort during this stage. • The patient has no signs of infection and the temperature is WNL. The normal WBC count during the postpartum period may be as high as 30,000. • The placenta is delivered during the third stage of delivery.
A nurse is caring for a patient who is 6 centimeters dilated. The nurse should follow the protocol for care of the patient in
active phase, first stage of labor • The patient is in the active phase of the first stage of labor when the cervix is dilated from 5 to 8 centimeters. • The first stage of labor is the period from onset of true labor to full cervical dilatation. This stage has three phases: latent, active, and transition. • Incorrect: The latent phase begins at the onset of regular uterine contractions and ends with rapid cervical dilatation of 1 to 5 centimeters. Contractions occur every 15 to 30 minutes and are 15 to 30 seconds in duration with mild intensity. • Incorrect: The transition phase is the last and final phase of the first stage of labor. During this phase, contractions reach their peak and intensity, occurring every 2 to 3 minutes. Cervical dilatation increases from 8 to 10 centimeters.
A patient delivers a 3,400-gram baby boy and is transferred to the postpartum unit. On the second postpartum day, the patient experiences tenderness and breast engorgement from breastfeeding. To relieve the patient's discomfort between feedings, the nurse should encourage her to
apply cold compresses to the breasts • Cold compresses should be applied to the breasts to reduce discomfort between feedings. This is appropriate for breastfeeding mothers and those who wish to formula feed. • Administer analgesics as prescribed if this comfort measure is unsuccessful. • Breast milk forms in response to the fall of estrogen and progesterone levels that follows delivery of the placenta. When milk production begins, the milk ducts become distended. The breasts become fuller, larger, and firmer. The distention is not limited to the milk ducts; it also occurs in the surrounding tissue. • The feeling of tension in the breasts on the third or fourth day is termed primary engorgement.
A nurse is caring for a woman in the first stage of labor. The fetal position is left occiput anterior. When her membranes rupture, the appropriate nursing actions would be to
assess the fetal heart rate evaluate the color and clarity of amniotic fluid • The first stage of labor is the longest and involves three phases: Latent Phase: onset to 4 cm dilation/contractions 15 to 30 min apart, 15 to 30 secs long Active Phase: 4 to 7 cm dilation/contractions 3 to 5 min apart, 30 to 60 secs long Transition: 8 cm to fully dilated/10 cm/contractions 2 to 3 min apart, 45 to 90 secs long • Counting the fetal heart rate before, during, and after contractions is important to ensure the well-being of the fetus. FHR should be 110 to 160 beats per minute. • Labor may begin with rupture of the membranes. If membranes rupture, first assess the FHR due to the risk of a collapsed umbilical cord. Then assess the color and clarity of the amniotic fluid to look for meconium staining, which would indicate fetal distress. Report any unusual findings immediately. • The physician does not need to be notified unless there are unusual findings because spontaneous rupture of the membranes is an expected occurrence. An exception is if the color of the amniotic fluid is yellow, which may indicate a blood incompatibility between the mother and the fetus, or if the fluid is meconium-stained, i.e., dark-colored. • Early rupture of the membranes can be advantageous if it causes the fetal head to settle snugly into the pelvis. However, intrauterine infection or prolapse of the umbilical cord are two risk factors associated with prolonged ruptured membranes during a long first stage of labor. • Measuring the amount of fluid should only be done if the patient is experiencing oligohydramnios or hydramnios. • Current clinical guidelines (Cochrane database) recommend keeping the number of vaginal examinations to a minimum to avoid promoting intraamniotic infection and for patient comfort. Routine VEs should only be performed on admission, every four hours in the first stage of labor, hourly in the second stage of labor, prior to administration of analgesia, and to evaluate for suspected complications.
Upon the delivery of a newborn, the APGAR score of the child within the first minutes was 5. This means
guarded, and may need clearing of airway • The APGAR is assessed at 1 minute and 5 minutes after birth. • An infant scoring at 5 means that the infant may need clearing of the airway and/or supplementary oxygen. • An infant scoring below 4 is considered critical and may need resuscitation. • A score of 7 to 10 is considered good, indicating that the baby doesn't need clearing of airways.
A 24-year-old primipara is now in her active phase of the first stage of labor. She tells the nurse that she wants general anesthesia to relieve intense pain. The nurse advises the patient that general anesthesia is not preferred for childbirth because
it carries the dangers of hypoxia and possible inhalation of vomitus during administration • General anesthesia refers to the deep sleep used for surgery where the patient is completely unaware of what is going on around them during the procedure. • This is never preferred for childbirth because it carries the dangers of hypoxia and possible inhalation of vomitus during administration. • Pregnant women are particularly prone to gastric reflux because of increased stomach pressure from the weight of the full uterus beneath it. • All women who receive general anesthesia must be observed closely in the postpartum period because of the possibility of uterine atony and hemorrhage.
A patient is on her third postpartum day when she tells the nurse that she sometimes has difficulty getting the infant to suck. She describes the infant opening the mouth when the breast touches her face but turning the head in the opposite direction. The nurse correctly explains that this behavior is related to
the rooting reflex, which suggests improper technique when positioning the infant • The mother may have pressed the baby's face, not the cheek, against her breast. This will cause the child to turn away from the mother. • To stimulate the rooting reflex, the mother should be instructed to brush her nipple against the infant's cheek or the side of her mouth. The baby will turn her head with an open mouth toward that side. • Incorrect: Tonic neck reflex is elicited through turning the newborn's head to the side. The arm on that side will extend, and the opposite arm will contract. This prepares the infant for voluntary reaching and may be a precursor to hand/eye coordination. • Incorrect: Extrusion reflex is not associated with feeding. A newborn will extrude any substance placed on the anterior portion of the tongue. This protective reflex prevents the swallowing of inedible substances.
A 27-year-old primigravida asks the nurse how much iron she needs during her pregnancy. The correct response of the nurse is
• During pregnancy, approximately 30 mg of iron is needed per day. • Non-pregnant women require about 18 mg of iron per day. • Iron is important for the formation of hemoglobin to carry oxygen throughout the body. Iron will be transferred to the fetus even if maternal iron intake is inadequate, but this causes depletion of the mother's iron stores, leading to maternal anemia.
A woman in the first trimester of her pregnancy is attending childbirth classes. What topics are most likely to be covered during this trimester?
• During the early stages of pregnancy, childbirth classes should cover topics such as warning signs of complications, nutrition, anatomy, and fetal development. Fetal development Anatomy of pregnancy Nutrition Complications and warning signs
A pregnant patient has delayed her first prenatal visit. She visits the clinic only after she starts to experience edema in her hands and feet. You note in the obstetrical history that this is the patient's third pregnancy, the first two ending with the death of the fetus or embryo. The first time was 8 weeks pregnant and the second was 28 weeks. The correct record of her pregnancy is
• This is the patient's third pregnancy, the first one ending at 8 weeks pregnant and the second at 28 weeks pregnant. • The correct record of her pregnancy is: Gravida 3, Para 1, Abortion 1. • Gravida is the number of times a woman has been pregnant regardless of the outcome of the pregnancy. • Para is the number of births carried past 20 weeks, including viable and nonviable stillbirths. • An abortion is defined as any interruption of a pregnancy before the fetus is viable (20 weeks gestation).
A patient at 34 weeks gestation calls the hospital with concerns of leaking vaginal fluid. The nurse should
• This woman needs to be assessed for premature rupture of membranes (PROM). • If a preterm woman experiences premature rupture of membranes, the fetus is in serious danger. After rupture, the seal to the fetus is lost and uterine and fetal infection may occur, as well as increased stress to the fetus due to changes in pressure from decreased amniotic fluid. It is necessary to report to the hospital immediately for prophylactic administration of broad-spectrum antibiotics. • Prophylactic administration of broad-spectrum antibiotics may reduce the risk of infection in the newborn. Labor may be induced. • After being assessed by the doctor, the woman may be placed on home bed rest if labor does not begin and if the fetus is too young to survive outside the uterus.
