Maternity
A primigravid client in early labor tells the nurse that she was exposed to rubella at about 14 weeks' gestation. After birth, the nurse should assess the neonate for which of the following?
Cardiac disorders. Rationale: Pregnant women who become infected with the rubella virus early in pregnancy risk having a neonate born with rubella syndrome. The symptoms include thrombocytopenia, cataracts, cardiac disorders, deafness, microcephaly, and motor and cognitive impairment. The most extensive neonatal effects occur when the mother is exposed during the first 2 to 6 weeks and up to 12 weeks' gestation, when critical organs are forming. Bulging fontanels are associated with increased intracranial pressure and meningitis, which can occur as the result of a b-hemolytic streptococcal infection.
A primiparous client who gave vaginal birth 1 hour ago voices anxiety because she has a nephew with Down syndrome. After teaching the client about Down syndrome, which of the following client statements indicates the need for additional teaching?
"Down syndrome is an abnormality that can result from a missing chromosome." Rationale: Down syndrome is a genetic abnormality that is caused by an extra chromosome that results in intellectual disability. The degree of disability is difficult to predict in a neonate, although most children born with Down syndrome have some degree of intellectual disability. Various methods can be used to determine whether a neonate has Down syndrome, which is commonly manifested by hypotonia, poor Moro reflex, flat facial profile, upslanting palpebral fissures, epicanthal folds, and hyperflexible joints. Genetic studies can be indicative of this disorder. Mothers older than 35 years are at a higher risk for having a child with Down syndrome. However, chromosomal abnormalities can occur regardless of the mother's age.
During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit". Which instruction by the nurse best addresses this nursing diagnosis?
"Support the neonate's head and back with the forearm." Rationale: To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with the forearm. A loose hold may increase the risk of dropping the neonate. The nurse must support the neonate's back and head. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.
The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material is characterized by which of the following?
A curdled appearance. Rationale: Vomited material has been digested and looks like curdled milk with a sour odor. Vomiting usually occurs between feedings and empties the stomach of its contents. It also tends to be forceful or projectile. In contrast, regurgitation is undigested material; it does not have a sour odor, and occurs during or immediately after feeding. Vomiting is unrelated to a feeding. Also, vomiting continues until the stomach is empty, while regurgitation is usually only about 1 to 2 teaspoons. Vomited material is typically white and curdled in appearance. A brownish color suggests old blood. Vomiting usually occurs between feedings, whereas regurgitation occurs during or immediately after feeding.
During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, a nurse should instruct the client to push the control button at which time?
At the beginning of each fetal movement Rationale: An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldn't allow accurate comparison of fetal movement and FHR changes.
The nurse is assisting in the birthing room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate childbirth. Which interventions should the nurse perform when caring for the client after this procedure? Select all that apply.
• Check the episiotomy repair site. • Apply ice to the perineum. • Administer pain medication, as prescribed. • Explain perineal care to the client when she can focus on the instructions. Rationale: Immediately following an episiotomy, the nurse should apply an ice pack to the perineal area to decrease swelling and pain. The nurse should also check the site to ensure that it is intact and assess for hematoma, edema, and drainage. The nurse should assess the client for pain and should administer analgesics as needed and prescribed. When the client is able, the nurse should instruct about perineal care. Episiotomy repair sites are not covered with dressings.
A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which action by the client requires intervention?
Applying a breast binder to support the breasts Rationale: Engorgement in a breast-feeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Binding the breasts isn't appropriate because the constriction will diminish the milk supply. Frozen cabbage leaves work well to reduce the pain and swelling and should be applied every 4 hours. Facing the shower head can stimulate the breasts and intensify the problem. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant.
Which of the following structures should be closed by the time the child is 2 months old?
Posterior fontanel Rationale: The posterior fontanel should be closed by age 2 months. The anterior fontanel and sagittal and frontal sutures should be closed by age 18 months.
A 20-year-old female's pregnancy is confirmed at a clinic. She says her partner will be excited but she is concerned because she herself is not excited. She fears this feeling may mean she will be a bad mother. The nurse should respond by:
reassuring her such feelings are normal in the beginning of pregnancy. Rationale: Misgivings and fears are common in the beginning of pregnancy. Such feelings don't necessarily mean that the client requires counseling at this time. Exploring the client's feelings may help her understand her concerns more deeply, but won't provide reassurance that her feelings are normal. The client may benefit by discussing her feelings with her partner, but the partner also needs to be reassured that these feelings are normal at this time.
While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which of the following stages of grief?
Shock Rationale: The physical appearance of the anomaly and the life-threatening nature of the disorder may result in shock to the parents. The parents may hesitate to form a bond with the neonate because of the guarded prognosis. Denial would be evidenced if the parents acted as if nothing were wrong. Bargaining would be evidenced by parental statements involving "if-then" phrasing, such as, "If the surgery is successful, I will go to church every Sunday." Anger would be evidenced if the parents attempted to blame someone, such as health care personnel, for the neonate's condition.
A primigravida in active labor is about 10 days post-term. The client desires a pudendal block anesthetic before childbirth. 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?
Perineum. Rationale: A pudendal block is used for vaginal births to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair. A pudendal block relieves pain in the perineum and vagina. It does not relieve discomfort in the back. A pudendal block relieves pain in the perineum and vagina. It does not relieve discomfort in the abdomen. A pudendal block relieves pain in the perineum and vagina. It does not relieve discomfort in the fundus.
When teaching a group of pregnant adolescents about reproduction and conception, the nurse is correct when stating that fertilization occurs:
in the first third of the fallopian tube. Rationale: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.
A 15-year-old unmarried primiparous client is being cared for in the hospital's birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which of the following responses would be most appropriate?
"I'll bring the baby to you for feeding." Rationale: After birth, the client should make the decision about how much she would like to participate in the neonate's care. Seeing and caring for the neonate commonly facilitates the grief process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold, and care for the neonate. The physician does not need to be contacted about the client's desire to see the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give the client permission to feed the baby.
A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The primary health care provider orders nalbuphine 15 mg slow I.V. push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the birth, which should the nurse avoid using with this client in this situation?
Naloxone hydrochloride. Rationale: Naloxone hydrochloride would not be used in a client who has a history of drug addiction. Naloxone hydrochloride would abruptly withdraw this woman from the drug she is addicted to as well as the nalbuphine. The withdrawal would occur within a few minutes of injection and, if severe enough, could jeopardize the mother and fetus. Lidocaine is a local anesthetic and numbs, rather than decreases the effects of naloxone hydrochloride. The local anesthetic and the pudendal block are both appropriate for this birth but are used to numb the maternal perineum during childbirth.
While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer an ordered hepatitis B intramuscular injection at 4 hours after birth. Which of the following actions should the nurse do first?
Apply clean gloves before administering the medication. Rationale: As part of standard precautions, the nurse should don a pair of clean gloves. Additionally, the site is cleaned thoroughly with an alcohol swab before the skin is injected. Sterile gloves are not necessary. Bathing the neonate is not necessary before giving the injection. Some research suggests that bathing removes the neonate's protective skin oils. Placing the neonate under the radiant warmer is not necessary unless the neonate's temperature is subnormal. The neonate's temperature has usually stabilized by 4 hours of age. Washing the injection site with povidone-iodine before giving the injection is not necessary because of the risk for possible allergy to iodine preparations.
A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action?
Discuss the unit's policy with the charge nurse. Rationale: Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the neonate's parents are married or if the mother is an emancipated minor. Therefore, the adolescent mother may not be able to legally make her own decisions about her parents' (the baby's grandparents') presence. She or her parents do have a say as to whether the father's parents can visit. The mother of the neonate does have a say in visitors seeing her baby. Because the family dynamics aren't clear in this scenario, the best answer would be to check with the charge nurse who knows the unit's policy. Although the neonate's father may have demanded to see the baby, the question doesn't indicate violent or threatening behavior; therefore, notifying security isn't necessary. The nurse can instruct the father's parents on how to gown and glove before visiting the neonate if they have permission to visit. Because the family dynamics aren't known, inviting everyone to gather in a conference room isn't advisable.
A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks' gestation tells the nurse that she takes mineral oil for occasional constipation. The nurse should instruct the client to do which of the following?
Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Rationale: Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed. Use of fruit juice is recommended for the client receiving iron supplementation to enhance its absorption. Mineral oil does not lead to vitamin C deficiency in pregnant clients. Mineral oil use is contraindicated during pregnancy and therefore should not be used. Increased fluids, fiber, and exercise are better choices to suggest for relief of constipation.
A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 ml. The nurse palpates the fundus 2 fingerbreadths above the umbilicus and off to the right side. What should the nurse do first?
Catheterize the client. Rationale: A uterine fundus located off to one side and above the level of the umbilicus is commonly the result of a full bladder. Although the client had voided, the client may be experiencing urinary retention with overflow. If anesthesia has been used for birth, the inability to void may be related to the lingering effects of anesthesia; however, that is not the case here. Physicians commonly write a one-time order for catheterization. After which, typically, enough edema has subsided making it easier and less painful for the client to void and completely empty her bladder. Administering ibuprofen would have no effect on the uterine fundus. Waiting to reassess in 1 hour could be detrimental since the client's distended bladder is interfering with uterine involution, predisposing her to possible hemorrhage. Administering a bolus of fluid would be inappropriate because it would only add to the client's full bladder.
During a visit to the clinic, a pregnant 25-year-old who began prenatal care at 10 weeks' gestation and is now in her third trimester reports frequent constipation. Which of the following suggestions by the nurse would be most helpful?
Eating at least four pieces of fruit daily. Rationale: Dietary measures such as increasing dietary intake of bulk and roughage (for example, eating at least four pieces of fruit each day) help to relieve constipation and should be suggested initially. Other nonpharmacologic measures include drinking a glass of hot fluid in the morning, increasing fluid intake, and exercising regularly. It is best not to suggest laxatives or suppositories because a client may become dependent on them. Additionally, the client should avoid taking any medication unless directed to do so by the primary health care provider. If the constipation is unrelieved by other nonpharmacologic measures, the primary health care provider may order glycerin suppositories. Avoiding highly seasoned foods would have no effect on constipation. However, if the client was experiencing heartburn, this might be an appropriate suggestion. Laxatives, even mild over-the-counter ones such as magnesium hydroxide, should be used only when diet, fluid intake, and exercise do not relieve the problem and after consultation with the nurse or primary health care provider.
