Maternity Final Fall 2018; Lowdermilk; Chapters 8-11 and 20-37
A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn's distress? a. Sepsis b. Phrenic nerve injury c. Hypoglycemia d. Respiratory distress syndrome
A
According to research, which risk factor for PPD is likely to have the greatest effect on the client postpartum? a. Prenatal depression b. Single-mother status c. Low socioeconomic status d. Unplanned or unwanted pregnancy
A
For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care? a. Snugly swaddling the infant and tightly holding the baby b. Playing soft music during feeding c. Administering chloral hydrate for sedation d. Feeding every 4 to 6 hours to allow extra rest between feedings
A
In caring for an immediate postpartum client, the nurse notes petechiae and oozing from her intravenous (IV) site. The client would be closely monitored for which clotting disorder? a. Disseminated Intravascular Coagulation (DIC) b. Hemorrhage c. HELLP syndrome d. Amniotic fluid embolism (AFE)
A
On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide? a. "You may hold your baby during the feeding." b. "You may only hold your baby's hand during the feeding." c. "Parents are not allowed to hold their infants who are dependent on oxygen." d. "Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you should hold the baby."
A
Preeclampsia begins at what point during the pregnancy? a. At placental implantation b. After 20 weeks gestation c. At conception d. At 12 weeks gestation
A
Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the client mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. This fetus is at the greatest risk for which condition? a. Macrosomia b. Congenital anomalies of the central nervous system c. Preterm birth d. Low birth weight
A
The nurse who is caring for a woman hospitalized for hyperemesis gravidarum would expect the initial treatment to involve what? a. Intravenous (IV) therapy to correct fluid and electrolyte imbalances b. Antiemetic medication, such as pyridoxine, to control nausea and vomiting c. Enteral nutrition to correct nutritional deficits d. Corticosteroids to reduce inflammation
A
What is one of the initial signs and symptoms of puerperal infection in the postpartum client? a. Temperature of 38° C (100.4° F) or higher on 2 successive days b. Fatigue continuing for longer than 1 week c. Profuse vaginal lochia with ambulation d. Pain with voiding
A
What is the primary purpose for magnesium sulfate administration for clients with preeclampsia and eclampsia? a. To prevent convulsions b. To prevent a boggy uterus and lessen lochial flow c. To shorten the duration of labor d. To improve patellar reflexes and increase respiratory efficiency
A
Which clinical findings would alert the nurse that the neonate is expressing pain? a. Cry face; eyes squeezed; increase in blood pressure b. High-pitched, shrill cry; withdrawal; change in heart rate c. Low-pitched crying; tachycardia; eyelids open wide d. Cry face; flaccid limbs; closed mouth
A
Which condition is considered a medical emergency that requires immediate treatment? a. Inversion of the uterus b. Hypotonic uterus c. ITP d. Uterine atony
A
Which explanation will assist the parents in their decision on whether they should circumcise their son? Select one: a. The circumcision procedure has pros and cons during the prenatal period. b. Circumcision is rarely painful, and any discomfort can be managed without medication. c. American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised. d. The infant will likely be alert and hungry shortly after the procedure
A
Which of the following antepartum tests is (are) used to evaluate a Maternal Serum Screening test that is negative for increased risk? a. Further followup test not necessary b. Biophysical profile c. Amniocentesis d. CVS
A
Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis
A Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps. Afterpains are also related to the increase of oxytocin released in response to infant suckling.
The perinatal nurse notes a rapid decrease in the fetal heart rate that does not recover immediately following an amniotomy. The most likely cause of this obstetrical emergency is: a. Prolapsed umbilical cord b. Vasa previa c. Oligohydramnios d. Placental abruption
A Amniotomy is the artificial rupture of membranes (AROM) to induce or augment labor. This is a common procedure seen in obstetrics. Risks associated with amniotomy include umbilical cord prolapse when the presenting part is not engaged. Vasa previa or rupture of fetal vessels unsupported by the placenta is a very rare situation and usually results in rapid fetal exsanguination in the presence of bloody fluid seen following AROM.
Which statement regarding the postpartum uterus is correct? a. After 2 weeks postpartum, it should be abdominally nonpalpable. b. At the end of the third stage of labor, the postpartum uterus weighs approximately 500 g. c. Postpartum uterus returns to its original (prepregnancy) size by 6 weeks postpartum. d. After 2 weeks postpartum, it weighs 100 g.
A By the end of the third stage of labor, the uterus weighs 1000g, 350 grams 2 weeks after labor and returns to its nonpregnant location by 6 weeks after birth when it will weigh 60 to 80 grams.
Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman spontaneously empty her bladder as soon as possible. If all else fails, what tactic might the nurse use? a. Inserting a sterile catheter b. Pouring water from a squeeze bottle over the woman's perineum c. Placing oil of peppermint in a bedpan under the woman d. Asking the physician to prescribe analgesic agents
A If all else fails, the woman will be straight cathed to relieve bladder distension.
A woman in preterm labor at 30 weeks of gestation receives two 12-mg intramuscular (IM) doses of betamethasone. What is the purpose of this pharmacologic intervention? a. To stimulate fetal surfactant production b. To suppress uterine contractions c. To maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy d. To reduce maternal and fetal tachycardia associated with ritodrine administration
A Important as baby may deliver preterm.
What are the most common causes for subinvolution of the uterus? a. Retained placental fragments and infection b. Uterine tetany and overproduction of oxytocin c. Postpartum hemorrhage and infection d. Multiple gestation and postpartum hemorrhage
A Involution is the return of the uterus to a nonpregnant state after birth. Subinvolution is the failure of the uterus to return to a non-pregnant state. The most common causes of subinvolution are retained placental fragments and infection
Tanya, a 30-year-old woman, is being prepared for a planned cesarean birth. The perinatal nurse assists the anesthesiologist with the spinal block and then positions Tanya in a supine position. Tanya's blood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm. The perinatal nurse's best response is to: a. Place Tanya in a left lateral tilt b. Discontinue Tanya's intravenous administration. c. Have naloxone (Narcan) ready for administration. d. Have epinephrine ready for administration.
A Reposition the woman after epidural or spinal anesthesia in a supine position with a left lateral tilt to decrease the pressure from the uterus on the inferior vena cava and to maintain placental perfusion.
Which client is at greatest risk for early PPH? a. Woman with severe preeclampsia on magnesium sulfate whose labor is being induced b. Primigravida in spontaneous labor with preterm twins c. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor d. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress
A The effects of magnesium sulfate puts this patient at greater risk for PPH than the other scenarios.
A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation for administration of Vitamin K to the infant, the nurse will explain to the parents that an injection of this medication: a. Influences the activation of coagulation factors to prevent delayed clotting and hemorrhagic disease b. Prevents high levels of unconjugated bilirubin in the newborn's blood c. Prevents the excessive loss of RBCs d. Aids the liver in regulation of blood glucose
A Vitamin K (phytonadione) influences the activation of coagulation factors II, VII, IX, and X. After birth, the neonate experiences a decrease in Vitamin K and is at risk for delayed clotting and for hemorrhage. An injection of Vitamin K is given as a prophylaxis to decreased the risk of bleeding.
Reports have linked third trimester use of selective serotonin uptake inhibitors (SSRIs) with a constellation of neonatal signs. The nurse is about to perform an assessment on the infant of a mother with a history of a mood disorder. Which signs and symptoms in the neonate may be the result of maternal SSRI use? (Select all that apply.) a. Irritability b. Shivering c. Fever d. Hyperglycemia e. Hypotonia
A, B, C
Tachysystole, previously referred to as hyperstimulation, is defined as: (Select one or more) a. Contractions lasting 2 minutes or longer b. Five or more contractions in 10 minutes over a 30-minute window c. Contractions occurring within 1 minute of each other d. Uterine resting tone below 20 mm/Hg
A, B, C Contractions lasting more than 2 minutes, five or more contractions in 10 minutes, and contractions occurring within 1 minute of each other describe the criteria for tachysystole. Uterine resting tone below 20 mm/Hg reflects normal uterine resting tone
The perinatal nurse is caring for Christy following the birth of her first child. Based on Christy's history, the RN recognizes that risk factors for postpartum depression include: Select one or more: a. Loss of friends based on upcoming divorce; family is unable to assist b. Separated from spouse pending divorce c. Unplanned cesarean delivery secondary to d. Good prenatal care with uneventful pregnancy
A, B, C Recognized risk factors for postpartum depression include a history of depression before pregnancy, depression or anxiety during pregnancy, poor quality relationship with partner, life/child care stresses, and complications of pregnancy/childbirth.
The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan? (Select all that apply). a. Water temperature for the infant's bath should be 100.4 degrees F. b. Do not cook while holding an infant c. Cover electrical outlets d. Remove strings from infant sleepwear, bedding, and pacifiers to prevent strangulation.
A, B, C, D
The perinatal nurse is teaching the new mother who has chosen to formula feed her infant. Appropriate instructions to be given to this mother include (select all that apply): a. Mix the formula according to manufacturer's instructions; do not overdilute or underdilute b. Periodically check the nipple for slow flow. c. Prepare only enough formula to last for 24 hours and discard open containers or prepared formula after 24 hours.
A, B, C, D Parents should be advised to read and follow the manufacturer's instructions explicitly when preparing the formula, because some require no water and some need to be diluted with water. Cold water should be used to mix the powder, only the amount to be used for each feeding should be prepared, and any unused formula should be discarded. The nipples should be checked periodically during feedings for correct flow and should be replaced regularly.
Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. What are possible causes of early miscarriage? (Select all that apply.) a. Chromosomal abnormalities b. Nausea and vomiting in early pregnancy c. Endocrine imbalance d. Systemic disorders e. Varicella
A, B, C, D, E Although most N/V in early pregnancy is not likely to relate to miscarriage, severe dehydration can reduce uterine circulation severely enough to impact a pregnancy
Which of the following lab tests are routinely performed on pregnant women? (Select all that apply). Select one or more: a. Syphilis test b. Rubella titer c. Genetic testing for cystic fibrosis d. 3 hr GTT e. Blood type
A, B, E 3 hr GTT is only done for abnormal 1 hrGTT or increased risk for diabetes in pregnancy
Which congenital anomalies can occur as a result of the use of antiepileptic drugs (AEDs) in pregnancy? (Select all that apply.) a. Neural tube defects b. Gastroschisis c. Congenital heart disease d. Cleft lip e. Diaphragmatic hernia
A, C, D
Which of the following nursing interventions are important in the prenatal care of the woman with prenatal depression? (Select all of the following). a. Maintain a caring relationship b. Counsel her on the importance of medication if the woman refuses it. c. Recommend she see a psychiatrist for management d. Educate the woman about depression and plan of care
A, C, D
The induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. What are appropriate indications for induction? (Select all that apply) a. Fetal death b. Convenience of the woman or her physician c. Postterm pregnancy d. Maternal fatigue and frustration at 38 weeks gestation e. Rupture of membranes at or near term
A, C, E
Karen, a G2 P2, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. What is the nurse's most appropriate actions? Select one or more: a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Assess for bladder distention and encourage patient to void.
A, D Massaging the fundus and resovling bladder distention will help to improve uterine atony and are the first interventions needed. B, C are interventions that can be performed after re-establishing uterine tone.
Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Because severe hypothyroidism is associated with infertility and miscarriage, it is not often seen in pregnancy. Regardless of this fact, the nurse should be aware of the characteristic symptoms of hypothyroidism. Which do they include? (Select all that apply.) a. Lethargy b. Weight loss c. Hot flashes d. Decrease in exercise capacity e. Cold intolerance
A, D, E
A primigravida at 40 weeks of gestation is having uterine contractions every 1½ to 2 minutes and states that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likelystatus of this woman's labor? a. She is experiencing precipitous labor. b. She is exhibiting hypotonic uterine dysfunction. c. She is exhibiting hypertonic uterine dysfunction d. She is experiencing a normal latent stage
B
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination, the nurse notices warmth and redness over an enlarged, hardened area. Which condition should the nurse suspect, and how will it be confirmed? a. von Willebrand disease (vWD); noting whether bleeding times have been extended b. Thrombophlebitis; using real-time and color Doppler ultrasound c. Idiopathic or immune thrombocytopenic purpura (ITP); drawing blood for laboratory analysis d. Disseminated intravascular coagulation (DIC); asking for laboratory tests
B
Another common pregnancy-specific condition is pruritic urticarial papules and plaques of pregnancy (PUPPP). A client asks the nurse why she has developed this condition and what can be done. What is the nurse's best response? a. PUPPP is associated with decreased maternal weight gain. b. The goal of therapy is to relieve discomfort. c. This common pregnancy-specific condition is associated with a poor fetal outcome. d. The rate of hypertension decreases with PUPPP.
B
In assisting the breastfeeding mother to position the baby, which information regarding positioning is important for the nurse to keep in mind? a. While supporting the head, the mother should push gently on the occiput. b. Whatever the position used, the infant is "belly to belly" with the mother. c. Women with perineal pain and swelling prefer the modified cradle position. d. The cradle position is usually preferred by mothers who had a cesarean birth.
B
In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. BPD b. ROP c. IVH d. NEC
B
Sally is 34 weeks pregnant and has a biophysical profile score of 8. She asks the nurse what does that mean? The nurse's best response is: a. "Since you are more than 36 weeks, it is best to deliver your baby as she may have asphyxia. I will call your doctor." b. "Your baby has low risk for having a problem having enough oxygen in her body and your doctor will probably want to do the test again soon. I will call your doctor. " c. " Your baby may be having some problems and your doctor may want to check to see if it is safe to deliver her soon. I will call your doctor." d. "Your baby is in danger of dying and you will probably need to deliver ASAP. I will call your doctor."
B
The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients? a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. c. Hearing screening is now mandated by federal law. d. Federal law prohibits newborn genetic testing without parental consent.
B
What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy? a. Performing a venipuncture for hemoglobin and hematocrit levels b. Assessing FHR and maternal vital signs c. Placing clean disposable pads to collect any drainage d. Monitoring uterine contractions
B
What is the most critical physiologic change required of the newborn after birth? a. Full function of the immune defense system b. Initiation and maintenance of respirations c. Maintenance of a stable temperature d. Closure of fetal shunts in the circulatory system
B
Which important component of nutritional counseling should the nurse include in health teaching for a pregnant woman who is experiencing cholecystitis? a. Teach the woman that the bulk of calories should come from proteins. b. Instruct the woman to eat a low-fat diet and to avoid fried foods. c. Assess the woman's dietary history for adequate calories and proteins. d. Instruct the woman to eat a low-cholesterol, low-salt diet.
B
Which infant is most likely to express Rh incompatibility? a. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor b. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor c. Infant who is Rh positive and a mother who is Rh positive d. Infant who is Rh negative and a mother who is Rh negative
B
Which nursing intervention is paramount when providing care to a client with preterm labor who has received terbutaline? a. Assess for hypoglycemia. b. Assess for dyspnea and crackles. c. Assess deep tendon reflexes (DTRs). d. Assess for bradycardia.
B
While providing care to the maternity client, the nurse should be aware that one of these anxiety disorders is likely to be triggered by the process of labor and birth. Which disorder fits this criterion? a. Phobias b. Posttraumatic stress disorder (PTSD) c. Obsessive-compulsive disorder (OCD) d. Panic disorder
B
The perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This stage of mothering is best described as: Select one: a. Taking in b. Taking hold c. Taking charge d. Taking time
B As the mother's physical condition improves, she begins to take charge and enters the taking-hold phase where she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe mother-infant interactions for signs of poor bonding, and if present, implement actions to facilitate attachment. see p 508 and Table 22-4
Pelvic floor exercises, also known as Kegel exercises, will help to strengthen the perineal muscles and encourage healing after childbirth. The nurse requests the client to repeat back instructions for this exercise. Which response by the client indicates successful learning? a. "I contract my thighs, buttocks, and abdomen." b. "I pretend that I am trying to stop the flow of urine in midstream." c. "I stand while practicing this new exercise routine." d. "I perform 10 of these exercises every day."
B Kegel exercises is a technique used to strengthen the muscles that support the pelvic floor. have the woman pretend she is trying to prevent the passage of gas, pretend she is trying to stop the flow of urine or think about how the vagina can contract around the penis during intercourse. Avoid straining or bearing down motions.
A woman with worsening preeclampsia is admitted to the hospital's labor and birth unit. The physician explains the plan of care for severe preeclampsia, including the induction of labor, to the woman and her husband. Which statement by the husband leads the nurse to believe that the couple needs further information? a. "I will give my wife ice chips to eat during labor." b. "Since we will be here for a while, I will call my mother so she can bring the two boys—2 years and 4 years of age—to visit their mother." c. "I will stay with my wife during her labor, just as we planned." d. "I will help my wife use the breathing techniques that we learned in our childbirth classes."
B Need to maintain quiet, low stimulant environment.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the nurse's highest priority at this time? a. Assessing the woman's vital signs b. Massaging the woman's fundus c. Calling the woman's primary health care provider d. Beginning an intravenous (IV) infusion of Ringer's lactate solution
B The initial intervention in management of excessive postpartum bleeding due to uterine atony is firm massage of the uterine fundus. Expression of any clots in the uterus, elimination of bladder distention, and continuous IV infusion of 10 to 40 units of oxytocin added to 1000ml of lactated ringers or normal saline solution also are primary interventions.
For which of the following conditions is Daily Fetal Movement Count indicated? (Select all that apply). a. Pregnant woman who is older than 35 years with no complications b. Mother with low amniotic fluid volume or oligohydraminos c. Mother with diabetes during pregnancy d. Mother who complains of headaches during pregnancy that are relieved with Tylenol
B, C
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate? (Select all that apply). a. absence of scalp hair, b. hypoglycemia c. meconium aspiration d. excessive vernix caseosa covering the skin e. increased amount of subcutaneous fat f. dry, cracked skin
B, C, F
The postpartum mother asks the nurse why is it so important to prevent cold stress in her baby- can't she shiver to stay warm? What should the nurse include in their response? (Select all that apply) a. Yes, your baby can shiver; but it important that we prevent her from needing to so. b. If your baby gets too cold and we don't help her, her body will use a lot of oxygen to try and get warm, which can ultimately lead to decrease oxygen to her lungs and body causing respiratory problems. c. Your baby will eventually warm up on her own, but it is best if we keep the hat on her head. d. No, your baby cannot shiver; therefore, it is important to prevent her from losing body heat.
B, D
Which of the following perinatal complications have been associated with untreated asymptomatic bacteriuria? (Select all that apply). a. congenital birth defects b. Preterm birth c. Low birth weight d. chorioamniotis
B, D
A 36 y/o pregnant woman has been diagnosed with polyhydraminos. The nurse knows this is based on which of the following? a. Amniotic fluid index of 20 cm b. Amniotic fluid index of 7 cm c. Amniotic fluid index of 30 cm d. Amniotic fluid index of 10 cm
C
A NICU nurse is caring for a full-term neonate being treated for group B streptococcus (GBS). The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is: a. "Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system?" b. "The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections?" c. "Approximately 15% to 40% of women have no symptoms but are carriers of group B streptococcus which is found in the vaginal and lower intestinal areas. What other questions do you have regarding your baby's health?" d. "I see that this is very upsetting for you. I will come back later and answer your questions."
C
A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Provide opportunities for grieving parents and family members to spend time with the baby d. Advise the parents to refrain from discussing the baby's death with their other children.
C
A pregnant woman at term is transported to the emergency department (ED) after a severe vehicular accident. The obstetric nurse responds and rushes to the ED with a fetal monitor. Cardiopulmonary arrest occurs as the obstetric nurse arrives. What is the highest priority for the trauma team? a. Quickly applying the fetal monitor to determine whether the fetus viability b. Transferring the woman to the surgical unit for an emergency cesarean delivery in case the fetus is still alive c. Starting cardiopulmonary resuscitation (CPR) d. Obtaining IV access, and starting aggressive fluid resuscitation
C
A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs: temperature 37.3° C, pulse rate 88 beats per minute, respiratory rate 10 breaths per minute, BP 148/90 mm Hg, absent deep tendon reflexes (DTRs), and no ankle clonus. The client complains, "I'm so thirsty and warm." What is the nurse's immediate action? a. To call for an immediate magnesium sulfate level b. Call the physician c. To discontinue the magnesium sulfate infusion d. To administer oxygen
C
An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths per minute with significant substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). What level of partial pressure of arterial oxygen (PaO2) indicates hypoxia? a. 89 mmHg b. 73 mmHg c. 45 mmHg d. 67 mmHg
C
During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective? a. "I will plan my diet based on the results of urine glucose testing." b. "I will need to eat 600 more calories per day because I am pregnant." c. "Diet and insulin needs change during pregnancy." d. "I can continue with the same diet as before pregnancy as long as it is well balanced."
C
In follow-up appointments or visits with parents and their new baby, it is useful if the nurse can identify infant behaviors that can either facilitate or inhibit attachment. What is an inhibiting behavior? a. The infant cries only when hungry or wet. b. The infant clings to the parents. c. The infant seeks attention from any adult in the room. d. The infant's activity is somewhat predictable
C
Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored maculopapular rash on the palms and around the mouth and anus. The newborn is displaying signs and symptoms of which condition? a. HIV b. Herpes simplex virus (HSV) infection c. Congenital syphilis d. Gonorrhea
C
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis? a. Calm mental status b. Cool, dry skin c. Urinary output of at least 30 ml/hr d. Absence of cyanosis in the buccal mucosa
C
To manage her diabetes appropriately and to ensure a good fetal outcome, how would the pregnant woman with diabetes alter her diet? a. Increase her consumption of protein. b. Reduce the carbohydrates in her diet. c. Eat her meals and snacks on a fixed schedule. d. Eat six small equal meals per day.
C
What form of heart disease in women of childbearing years generally has a benign effect on pregnancy? a. Rheumatic heart disease b. Congenital heart disease c. Mitral valve prolapse d. Cardiomyopathy
C
When assessing the apical pulse (point of maximal impulse: PMI) of the neonate, the stethoscope should be placed at the: a. First or second intercostal space b. Third intercostal space c. Fourth intercostal space d. Fifth intercostal space
C
Which instruction should the nurse provide to reduce the risk of nipple trauma? a. Wash the nipples daily with mild soap and water. b. Limit the feeding time to less than 5 minutes. c. Position the infant so the nipple is far back in the mouth. d. Assess the nipples before each feeding.
C
A client with maternal phenylketonuria (PKU) has come to the obstetrical clinic to begin prenatal care. Why would this preexisting condition result in the need for closer monitoring during pregnancy? a. A pregnant woman is more likely to die without strict dietary control. b. PKU is a recognized cause of preterm labor. c. The fetus may develop neurologic problems. d. Women with PKU are usually mentally handicapped and should not reproduce.
C pp 707-708
A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment after childbirth. Recognizing the needs of women during this stage, how should the nurse respond? a. Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session while she is in the hospital. b. Foster an active role in the baby's care. c. Provide time for the mother to reflect on the events of her labor and delivery. d. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs.
C For the first 24 hours and up to 48 hours the focus is on the self and meeting of basic needs. The mother tends to be excited, talkative, and have a desire to review the birth experience.
A woman with worsening preeclampsia is admitted to the hospital's labor and birth unit. The physician explains the plan of care for severe preeclampsia, including the induction of labor, to the woman and her husband. Which statement by the husband leads the nurse to believe that the couple needs further information? a. "I will give my wife ice chips to eat during labor." b. "Since we will be here for a while, I will call my mother so she can bring the two boys—2 years and 4 years of age—to visit their mother." c. "I will stay with my wife during her labor, just as we planned." d. "I will help my wife use the breathing techniques that we learned in our childbirth classes."
C Need to maintain quiet, low stimulant environment.
A woman who is 12 weeks postpartum presents with the following behavior: she reports severe mood swings and hearing voices, believes her infant is going to die, she has to be reminded to shower and put on clean clothes, and she feels she is unable to care for her baby. These behaviors are associated with which of the following? a. Postpartum blues b. Postpartum depression c. Postpartum psychosis d. Maladaptive mother-infant attachment
C Postpartum psychosis (PPP) is a variant of bipolar disorder and is the most serious form of postpartum mood disorders. Onset of symptoms can be as early as the 3rd postpartum day. Assessment findings include paranoia, delusions associated with the baby, mood swings, extreme agitation, confused thinking, inability to care for self or infant, and strange beliefs.
A woman who is 30 weeks of gestation arrives at the hospital with bleeding. Which differential diagnosis would not be applicable for this client? a. Placenta previa b. Cord insertion c. Spontaneous abortion d. Abruptio placentae
C Spontaneous abortion occurs prior to 20 weeks
A 26-year-old pregnant woman, gravida 2, para 1-0-0-1, is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, which diagnostic procedure will the client most likely have performed? a. Contraction stress test (CST) b. Internal fetal monitoring c. Transvaginal ultrasound for placental location d. Amniocentesis for fetal lung maturity
C The symptoms, bright red and painlessvaginal bleeding, indicate placental previa. An ultrasound can confirm this diagnosis.
A nurse notes that an Eskimo woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. While evaluating this client's behavior with her infant, what realization does the nurse make? Select one: a. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn. b. The woman is inexperienced in caring for a newborn. c. What appears to be a lack of interest in the newborn is, in fact, the cultural way of demonstrating intense love by attempting to ward off evil spirits. d. Extra time needs to be planned for assisting the woman in bonding with her newborn
C What appears to be a lack of interest in the newborn is, in fact, the cultural way of demonstrating intense love by attempting to ward off evil spirits.
If a woman is at risk for thrombus and is not ready to ambulate, which nursing intervention would the nurse use? (Select all that apply.) a. Having her sit in a chair b. Promoting bed rest c. Having her flex, extend, and rotate her feet, ankles, and legs d. Immediately notifying the physician if a positive Homans sign occurs e. Putting her in antiembolic stockings (thromboembolic deterrent [TED] hose) and/or sequential compression device (SCD) boots
C, D, E Prophylactics for thrombus include ambulation or movement, antiembolic stockings, and/or sequential compression device. A positive Homans sign is when passive dorsiflextion of the foot results in calf pain that is often associated with warmth and redness of the calf.
Which of the following is true regarding physiologic jaundice? (Select all that apply). a. Jaundice is noted within 24 hours after birth b. It is recommended the mother stop breastfeeding until jaundice resolves c. Jaundice is noted 24 hours after birth d. Jaundice persists longer than 14 days of life in a term infant e. Jaundice is more common in preterm infants
C, E
A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice is also known as breast milk jaundice. b. Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types. c. Physiologic jaundice occurs during the first 24 hours of life. d. Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life
D
A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and inconsolably cries until held. What is the correct nursing diagnosis beginning with "ineffective coping, related to"? a. Severe immaturity b. Behavioral responses c. Physiologic distress d. Environmental stress
D
A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse? a. Weight gain of 0.5 kg during the past 2 weeks b. Pitting pedal edema at the end of the day c. Blood pressure (BP) increase to 138/86 mm Hg d. Dipstick value of 3+ for protein in her urine
D
A woman at 28 weeks of gestation experiences blunt abdominal trauma as the result of a fall. The nurse must closely observe the client for what? a. Alteration in maternal vital signs, especially blood pressure b. Complaints of abdominal pain c. Hemorrhage d. Placental abruption
D
An infant was born 2 hours ago at 37 weeks of gestation and weighs 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of what condition? a. Seizures b. Birth injury c. Hypocalcemia d. Hypoglycemia
D
In contrast to placenta previa, what is the most prevalent clinical manifestation of Grade 3 abruptio placentae? a. Bleeding b. Cramping c. Intermittent uterine contractions d. Intense abdominal pain
D
Postoperative care of the pregnant woman who requires abdominal surgery for appendicitis includes which additional assessment? a. Signs and symptoms of infection b. Vital signs and incision c. Intake and output (I&O) and intravenous (IV) site d. Fetal heart rate (FHR) and uterine activity
D
The client is being induced in response to worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active, despite several hours of oxytocin administration. She asks the nurse, "Why is this taking so long?" What is the nurse's most appropriate response? a. "I don't know why it is taking so long." b. "Your baby is just being stubborn." c. "The length of labor varies for different women." d. "The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor."
D
The nurse is performing an assessment on a client who thinks she may be experiencing preterm labor. Which information is the most important for the nurse to understand and share with the client? a. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver. b. Braxton Hicks contractions often signal the onset of preterm labor. c. Because all women must be considered at risk for preterm labor and prediction is so variable, teaching pregnant women the symptoms of preterm labor probably causes more harm through false alarms. d. Diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.
D
The nurse is preparing to administer methotrexate to the client. This drug is most often used for which obstetric complication? a. Abruptio placentae b. Complete hydatidiform mole c. Missed abortion d. Unruptured ectopic pregnancy
D
Which conditions are infants of diabetic mothers (IDMs) at a higher risk for developing? a. Hyponatremia b. Sepsis c. Iron deficiency anemia d. Respiratory distress syndrome
D
Which statement regarding the laboratory test for glycosylated hemoglobin Alc is correct? a. This laboratory test is a snapshot of glucose control at the moment. b. This laboratory test is performed on the woman's urine, not her blood. c. The laboratory test for glycosylated hemoglobin Alc is performed for all pregnant women, not only those with or likely to have diabetes. d. This laboratory test measures the levels of hemoglobin Alc, which should remain at less than 7%
D
The nurse is using the New Ballard Scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a. Smooth, pink skin with visible veins b. Faint red marks on the soles of the feet c. Abundant lanugo d. Flexed posture
D 553
If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument? a. Insert the compressed bulb into the center of the mouth. b. Remove the bulb syringe from the crib when finished. c. Avoid suctioning the nares. d. Suction the mouth first
D 567
As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Based on the most recent evidence, which information is incorrect and should be discussed with parents? a. Keep the infant away from secondhand smoke. b. Prevent exposure to people with upper respiratory tract infections. c. Avoid loose bedding, water beds, and beanbag chairs. d. Place the infant on his or her abdomen to sleep
D Back to Sleep- Infants should always be placed on their backs to sleep.
A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As the nurse prepares her for discharge, she begins to cry. The nurse's next action should be what? a. Explain that she is experiencing postpartum blues. b. Point out how lucky she is to have a healthy baby. c. Assess her for pain. d. Allow her time to express her feelings
D The nurse needs to hear from the patient why she is crying before offering a response.
Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a. The mother should pump every 2 to 3 hours, including during the night. b. The mother should only pump as much milk as the infant can drink. c. A glass of wine just before pumping will help reduce stress and anxiety. d. Premature infants more easily digest breast milk than formula.
D The question asks- The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? This answer best reflects knowledge of lactation, as indicated in this statement.
A patient, G1 P0, is admitted to the labor and delivery unit for induction of labor. The following assessments were made on admission: Bishop score of 4, fetal heart rate 140s with moderate variability and no decelerations, TPR 98.6F, 88, 20, BP 120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrant the removal of the Cervidil (dinoprostone)? a. Bishop score of 5 b. Fetal heart of 152 bpm c. Respiratory rate of 24 rpm d. More than 5 contractions in 10 minutes
D This is hyperstimulation
A woman gave birth to an infant boy 10 hours ago. Where does the nurse expect to locate this woman's fundus? a. Midway between the umbilicus and the symphysis pubis b. 2 centimeters below the umbilicus c. Nonpalpable abdominally d. 1 centimeter above the umbilicus
D Within 12 hours the fundus can rise to approximately 1 cm above the umbilicus. By 24 hours after birth the uterus is about the same size as it was at 20 weeks of gestation. The fundus descends 1 to 2cm every 24 hours. The uterus should not be palpable abominally after 2 weeks and should have returned to its nonpregannt location by 6 weeks after birth.
Allison is 32 weeks pregnant presents to L&D and tells the nurse she has not felt her baby move in 48 hours. The nurse begins electronic fetal monitoring and notes the baby's heart rate is in the 130's. The nurse contacts Allison's physician to obtain an order for which of the following tests? a. Fetal fibronectin b. Maternal Serum Screening Test c. Biophysical profile d. Leopolds Maneuvers e. Non stress Test
E
PPH may be sudden and result in rapid blood loss. The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss. Astute assessment of the client's circulatory status can be performed with noninvasive monitoring. Match the type of noninvasive assessment that the nurse would perform with the appropriate clinical manifestation or body system. Inspection Skin color, temp, tugor Palpation Arterial pulses Observation Presence or absence of anxiety Measurement Pulse oximetry Auscultation Heart pulses
Inspection Skin color, temp, tugor Palpation Arterial pulses Observation Presence or absence of anxiety Measurement Pulse oximetry Auscultation Heart pulses
